Chapter 36 Vascular Disorders 1

Learning Objectives Identify specific anatomic and physiologic factors that affect the vascular system and tissue oxygenation. Indicate appropriate parameters for assessing a patient with peripheral vascular disease, aneurysm, and aortic dissection. Discuss tests and procedures used to diagnose selected vascular disorders and the nursing considerations for each. Describe the pathophysiology, signs and symptoms, complications, and medical or surgical treatments for selected vascular disorders. Assist in developing a plan of care for patients with selected vascular disorders.

Anatomy and Physiology of the Vascular System 3

Arteries Vessels that carry blood away from the heart toward the tissues Thick-walled structures with three layers: intima, media, and adventitia Smooth muscles encircle and control the diameter What is the largest artery in the body? Contraction of the muscles constricts the vessels, whereas relaxation of the muscles results in vessel dilation. 4

Capillaries Arterioles branch into progressively smaller vessels, then form the capillaries A single layer of endothelial cells that allow the efficient delivery of nutrients and oxygen into the tissues and the removal of metabolic wastes from the tissues Tiny vessels that receive blood from the capillaries are venules, the smallest veins Red blood cells have to conform to the size of the capillaries by changing their shape to fit through the small diameter. How is the distribution of capillaries determined? Because capillaries have less smooth muscle than the arteries, the amount of blood in the capillary is controlled by sphincters on the arteriolar side of the capillary. 5

Figure 36-1 6

Figure 36-2 7

Veins The vessels that return blood to the heart Formed as capillaries organize into larger and larger vessels Composed of the same layers as the arteries and arterioles, but the layers are less defined The venous system is less sturdy and more passive than the arterial system. Because the walls of the veins and venules are thinner and less muscular, they can stretch more than those of the arterial system. How much of the body’s total blood volume is housed in the venous system? 8

Veins Valves Innervation Allow blood to move in only one direction and prevent backflow of blood in the extremities Innervation The sympathetic nervous system acts on the musculature of the veins to stimulate venoconstriction Blocking of sympathetic nerve stimulation permits venodilation The venous system is equipped with valves that are composed of endothelial leaflets. Skeletal muscle contractions compress the veins, forcing blood back toward the heart; this action reduces venous pooling and increases the circulating blood volume. How are carbon dioxide and other metabolic wastes eliminated? 9

Figure 36-3 10

Lymph Vessels Lymph system: small, thin-walled vessels that resemble the capillaries Accommodate the collection of lymph fluid from the peripheral tissues and the transportation of the fluid to the venous circulatory system Lymph fluid is composed of plasma-like fluid, large protein molecules, and foreign substances Movement by the contraction of muscles that encircle the lymphatic walls and surrounding tissues Because the lymph system interacts with the venous system, it is classified as part of the cardiovascular system. What are the two main trunks of the lymph system? 11

Factors That Affect Blood Flow Resistance Controlled by the diameter of the vessels When vascular diameter increases, peripheral resistance falls and blood flow increases When vascular diameter decreases, peripheral resistance increases, thereby reducing blood flow The sympathetic nervous system plays a major role in adjusting vascular resistance. What factors cause changes in vascular resistance? 12

Factors That Affect Blood Flow Blood viscosity Thickness of the blood Can be affected by changes in the proportions of the solid or liquid components Capillary permeability affects blood viscosity If capillary permeability altered, the amount and direction of fluid movement changes; results in change in viscosity What is hemoconcentration? When the proportion of serum to solid components in the blood is higher than normal, blood is less viscous and the kidneys excrete excess fluid. 13

Age-Related Changes Arteriosclerosis Stiffening of the vessel walls Delivery of oxygen and nutrients to tissues is compromised; buildup of waste products in tissue Decrease of hemoglobin Produces a decline in the oxygen-carrying capacity of the blood Slowing heart rate and decrease in stroke volume The stiffening of the peripheral vessels associated with aging occurs in both the intima and the media of the vessel wall. What occurs when there is a loss of elasticity in the peripheral vessels? 14

Chief Complaint and History of Present Illness Focuses on the six classical “Ps” of peripheral vascular disease: pain, pulselessness, poikilothermy, pallor, paresthesia, and paralysis 15

Past Medical History Document a history of hypertension, coronary artery disease, myocardial infarction, or atherosclerosis 16

Family History Relevant diseases: hypertension, coronary artery disease, myocardial infarction, atherosclerosis, aneurysm, and diabetes 17

Assessment of the Vascular System Review of systems Changes associated with PVD: thick, brittle nails; shiny, taut, scaly, dry skin; skin temperature variations; skin ulcerations; muscle atrophy; localized redness and hardness; and hair loss on the extremities Assess for chest pain and dyspnea Assess for symptoms of aneurysms: hoarseness, dysphagia, dyspnea, abdominal or back pain, or swelling of the head and arms How are a Homans’ sign and an Allen’s test performed? 18

Assessment of the Vascular System Functional assessment Determines the effect of the disease on the patient’s life 19

Assessment of the Vascular System Physical examination Inspect the skin for color and lesions Capillary refill time in the nail beds Palpate affected areas to evaluate temperature, detect edema, and assess peripheral pulses Homans’ sign Allen test 20

Figure 36-4 21

Diagnostic Tests and Procedures Ultrasonography Pressure measurements Plethysmography Segmental plethysmography Exercise (treadmill) test Angiography Tomographic angiography Magnetic resonance angiography Arteriography Venography 22

Therapeutic Measures Exercise programs Stress management Pain management Smoking cessation Elastic stockings Intermittent pneumatic compression Positioning Thermotherapy Protection Patient teaching Embolectomy is the removal of a blood clot located in a large vessel. Percutaneous transluminal angioplasty is used to gain access to the arteries in the lower extremities in people who are poor surgical risks. Endarterectomy: emboli and atherosclerotic plaque are stripped away from the intima of the vessel, and the vessel is surgically closed. A sympathectomy may be done to improve vascular circulation when the patient has intermittent claudication. What disorder is treated with vein ligation and stripping? Sclerotherapy is a method for managing varicose veins, primarily for cosmetic treatment of small, prominent varicosities. 23

Figure 36-5 24

Figure 36-6 25

Therapeutic Measures Surgical procedures Embolectomy Percutaneous transluminal angioplasty Endarterectomy Sympathectomy Vein ligation and stripping Sclerotherapy 26

Nursing Care Related to Surgery Preoperative nursing care Patient with severe cardiovascular disease may have activity restrictions to reduce demands on circulatory system until the surgical procedure is done Affected extremity should be maintained in a level or slightly dependent position as ordered Optimize peripheral circulation: keep extremity warm Protect the limb from further injury If peripheral pulses disappear, what should be suspected? During the recovery period, emphasize that the patient should not cross the legs or place the affected extremity in a dependent position for long periods of time. Elevating the extremity helps prevent edema. 27

Nursing Care Related to Surgery Postoperative nursing care Primary goal of the postoperative period is to stimulate circulation by encouraging movement and preventing stasis within the extremity If peripheral pulses disappear, what should be suspected? During the recovery period, emphasize that the patient should not cross the legs or place the affected extremity in a dependent position for long periods of time. Elevating the extremity helps prevent edema. 28

Nursing Care Related to Surgery Drugs Anticoagulants Thrombolytics Platelet aggregation inhibitors Vasodilators Nonsteroidal anti-inflammatory drugs Analgesics 29

Nursing Care Related to Surgery Dietary interventions Low-fat diets reduce serum cholesterol levels Weight-reduction diet if the patient is obese Adequate vitamin B, vitamin C, and protein needed to promote healing and improve tissue integrity Why is obesity a concern for the vascular system? 30

Disorders of the Peripheral Vascular System 31

Arterial Embolism Pathophysiology Usually forms in the heart, but a roughened atheromatous plaque in any artery also can lead to thrombus formation If a thrombus breaks loose, it becomes an embolus and travels through the circulatory system until it lodges in a vessel, blocking blood flow distal to the occlusion The development of an arterial embolism is a potentially life-threatening event. What do the affects of arterial occlusion depend on? 32

Arterial Embolism Signs and symptoms Severe, acute pain Gradual loss of sensory and motor function in the affected areas Pain aggravated by movement or pressure Absent distal pulses Pallor and mottling (irregular discoloration) Sharp line of color and temperature demarcation: tissue beyond the obstruction is pale and cool 33

Arterial Embolism Medical and surgical treatment Intravenous anticoagulants and thrombolytic agents Embolectomy When should anticoagulants and thrombolytic agents not be used? 34

Interventions Ineffective Tissue Perfusion Fear Impaired Physical Mobility Impaired Skin Integrity Ineffective Therapeutic Regimen Management 35

Peripheral Arterial Occlusive Disease Atherosclerosis obliterans, arterial insufficiency, and peripheral vascular disease Pathologic changes in the arteries, typically plaque formations that arise where the arteries branch, veer, arch, or narrow Common sites for arterial occlusion are the distal superficial femoral and the popliteal arteries Occlusions prevent delivery of oxygen and nutrients to the tissues Hypoxia affects all tissues distal to the occlusion Peripheral nerves and muscles are more susceptible to harm from hypoxia than the skin and subcutaneous tissues. What are the effects of severe oxygen deprivation? 36

Figure 36-7 37

Peripheral Arterial Occlusive Disease Signs and symptoms Intermittent claudication Absence of peripheral pulses below occlusive area Rest pain Tingling or numbness or both in the toes Extremity is cold, numb, and pale Shiny, scaly skin; subcutaneous tissue loss; hairlessness on the affected extremity; and ulcers with a pale gray or yellowish hue, especially at ankles What may cause the toenails to thicken? If one extremity is affected more than the other, size differences between the extremities may be apparent. 38

Peripheral Arterial Occlusive Disease Medical diagnosis Duplex imaging Angiography 39

Peripheral Arterial Occlusive Disease Medical and surgical treatment Lifestyle changes Smoking cessation, exercise, weight management Treatment for hypertension, hyperlipidemia, or diabetes Drugs for claudication: cilostazol and pentoxifylline Surgical interventions Percutaneous transluminal angioplasty, atherectomy, and endarterectomy What frequency of exercise programs have been found to be most successful with peripheral arterial disease? An endarterectomy with a graft is the surgical replacement of a diseased segment of an artery with a graft of some type—either synthetic or from another blood vessel. Percutaneous transluminal angioplasty (PTA) is used to enlarge the interior diameter of the blood vessel. 40

Peripheral Arterial Occlusive Disease Assessment Assess the pulses distal to the surgical site and compare with the same pulses in the unaffected extremity Assess vital signs, color, and temperature of affected extremity, fluid intake and output, central venous pressure, and mental status Cessation of a pulse suggests possible arterial occlusion, and the surgeon must be notified immediately. 41

Peripheral Arterial Occlusive Disease Interventions Activity Intolerance Chronic Pain Impaired Skin Integrity Pain Disturbed Body Image Ineffective Tissue Perfusion Risk for Infection Decreased Cardiac Output Ineffective Therapeutic Regimen Management Impaired Physical Mobility 42

Thromboangiitis Obliterans Also called Buerger’s disease Inflammatory thrombotic disorder of arteries and veins in lower and upper extremities Cause is unknown, but it occurs only in smokers Signs and symptoms: intermittent claudication, rest pain, skin color/temperature changes in affected areas, cold sensitivity, abnormal sensation, ulceration, gangrene Diagnosis based on physical findings and arteriography Most important treatment is smoking cessation Palliative treatments include sympathectomy and drugs, such as calcium channel blockers, antibiotics, and anticoagulants 43

Raynaud’s Disease Pathophysiology Signs and symptoms Medical diagnosis Intermittent constriction of arterioles; affects hands primarily, but it can affect the toes and tip of the nose Signs and symptoms Chronically cold hands, numbness, tingling, and pallor During an arterial spasm, the skin color changes from pallor to cyanosis to redness Medical diagnosis Based on the signs and symptoms and on the absence of evidence of occlusive vascular disease The cause of this condition is unknown, but it may be related to hypersensitivity to cold or release of serotonin. Who is primarily affected by Raynaud’s disease? Finger involvement is not symmetric, and the thumb is not usually affected. 44

Raynaud’s Disease Medical and surgical treatment Drugs Sympathectomy Calcium channel blockers, transdermal nitroglycerin, an endothelin receptor antagonist, phosphodiesterase inhibitors, and intravenous prostaglandins Sympathectomy What are the goals of medical treatment for Raynaud’s disease? 45

Interventions Pain and Ineffective Tissue Perfusion Fear 46

Aneurysms Pathophysiology A dilated segment of an artery caused by weakness and stretching of the arterial wall; can be congenital or acquired What conditions are associated with congenital aneurysms? Acquired aneurysms can be caused by arteriosclerosis, trauma, or infection. The most common cause of aneurysms is atherosclerosis. 47

Aneurysms Signs and symptoms Thoracic aneurysms usually have no symptoms, though some report deep, diffuse chest pain If aneurysm puts pressure on the recurrent laryngeal nerve, patient may complain of hoarseness Pressure on the esophagus may cause dysphagia If superior vena cava compressed, edema of the head and arms Signs of airway obstruction may be present if the aneurysm presses against pulmonary structures Abdominal aneurysms may be palpated as a pulsating mass in the area slightly left of the umbilicus 48

Aneurysms Complications Medical diagnosis Rupture, thrombus formation that obstructs blood flow, emboli, pressure on surrounding structures Medical diagnosis Physical findings, echocardiography, ultrasonography, computed tomography, aortography Medical and surgical treatment Repair of aneurysms done by replacing the dilated segment of the artery with synthetic graft or, in some cases, by suturing or patching the defective area Repair is usually done as soon as possible but may be delayed until the patient is evaluated for other problems that increase surgical risk. What factors affect the decision to repair an aneurysm? 49

Aneurysms Preoperative nursing care It is important to document chronic conditions, such as emphysema or heart disease, that increase the risk of postoperative complications 50

Postoperative Nursing Care Assessment Monitor vital signs, hemodynamic status, renal function, and fluid balance. Inspect and palpate the extremities for color, warmth, and peripheral pulses 51

Postoperative Nursing Care Interventions Impaired Urinary Elimination Risk for Injury Ineffective Breathing Patterns Decreased Cardiac Output Ineffective Tissue Perfusion 52

Aortic Dissection A small tear in the intima permits blood to escape into the space between the intima and the media Blood accumulates between the layers, causing the media to split lengthwise The split may extend up and down the aorta, where it can occlude major arteries 53

Aortic Dissection If no complications, patient managed with antihypertensives and drugs to decrease the strength of cardiac contractions Otherwise, affected area is replaced with a synthetic graft A key aspect of postoperative care: keep blood pressure at lowest possible level In other respects, the care is similar to that of a patient who has had an aneurysm repair 54

Varicose Vein Disease Pathophysiology Varicosities are dilated, tortuous, superficial veins, often the saphenous veins in the lower extremities Dilation of the vessels results from incompetent valves in the veins Classified as primary (only superficial veins affected) and secondary (characterized by deep vein obstruction) What are the risk factors of varicose vein disease? In addition to peripheral veins, varicosities can occur in other areas such as the esophageal and hemorrhoidal veins. Incompetent valves cannot be repaired. 55

Varicose Vein Disease Signs and symptoms Oversized, discolored (purplish), and tortuous veins Dull aching sensations when standing or walking; a feeling of heaviness in the affected legs; muscle cramps, especially at night; increased muscular fatigue in the affected area; and ankle edema The onset of varicose vein disease is gradual, but the condition is progressive. What are symptoms that postphlebitic syndrome has developed? 56

Figure 36-8 57

Varicose Vein Disease Varicose vein disease Medical diagnosis Based on their appearance and duplex ultrasonography Medical and surgical treatment Avoid restrictive garments, prolonged standing or sitting, crossing the legs or knees, and injury to compromised areas Weight reduction Support stockings Sclerotherapy or laser therapy Ligation and stripping Conservative treatments of varicosities are used whenever possible. When would surgery be recommended for varicose vein disease? 58

Varicose Vein Disease Assessment Health history determines pain, edema, cramps, and muscle fatigue Note family history of varicose veins Patient’s occupation and usual activities Physical examination: inspect the legs for color, edema, turgor, and capillary refill Palpate the legs for tenderness 59

Varicose Vein Disease Interventions Improve activity tolerance and manage pain Surgical patient Patient teaching 60

Venous Thrombosis Pathophysiology Phlebitis Thrombophlebitis Inflammation of the vein wall Thrombophlebitis Clot has formed at the site of inflammation within a vein Phlebothrombosis Presence of a thrombus in a vein as a result of stasis, deviation of the intima, or hypercoagulability Deep vein thrombosis Clot in a deep vein rather than in superficial vessels 61

Venous Thrombosis Risk factors Prescribed bed rest Surgery for people older than 40 years of age Leg trauma resulting in immobilization from casts or traction Previous venous insufficiency Obesity Use of oral contraceptives What is Virchow’s triad? 62

Venous Thrombosis Signs and symptoms Deep vein Superficial vessels Edema, warmth, and tenderness at the area of compromise; positive Homans’ sign Superficial vessels Pain, redness, warmth, or tenderness in the affected area 63

Venous Thrombosis Medical diagnosis Venography, Doppler ultrasonography, and duplex ultrasonography Lung scan, pulmonary angiogram, or spiral CT scan if pulmonary embolism is suspected 64

Venous Thrombosis Medical and surgical treatment Anticoagulant or thrombolytic therapy, or both Patient teaching about the disease; ongoing assessment for pulmonary emboli; bed rest; elevation of the extremity; warm, moist soaks to the affected area; and antiembolism hose Surgery considered when patient cannot receive anticoagulants or thrombolytic therapy or when high possibility of pulmonary emboli What are the goals of treatment for venous thrombosis? 65

Venous Thrombosis Interventions Impaired Skin Integrity Pain Anxiety Activity Intolerance Ineffective Tissue Perfusion Impaired Gas Exchange Ineffective Therapeutic Regimen Management 66

Chronic Venous Insufficiency Pathophysiology Culmination of long-standing pressure that stretches the veins and damages the valves Signs and symptoms Edema around the lower legs, pain, brownish skin discoloration (stasis dermatitis), and stasis ulcerations Heaviness or dull ache in the calf or thigh Skin temperature is cool, and nails are normal Feet and ankles often cyanotic when in a dependent position Ulcers may form because of the pressure exerted by edema or as a result of trauma. Where do ulcers most often develop? 67

Chronic Venous Insufficiency Medical diagnosis Physical examination 68

Chronic Venous Insufficiency Medical and surgical treatment Compression Elastic or compression stockings and pneumatic compression device If patient has an ulcer, special dressings, systemic antibiotics, topical débriding agents such as Elase, and Unna boots Hyperbaric oxygen therapy Unna boots are medicated dressings used to allow the patient to be ambulatory while protecting the ulcer in a sterile environment. What is the overall goal for medical management of ulcerations? 69

Chronic Venous Insufficiency Assessment Inspect the lower extremities for rubor and stasis dermatitis, palpate skin temperature, and determine the presence of pain in the affected extremity 70

Chronic Venous Insufficiency Interventions Ineffective Tissue Perfusion Disturbed Body Image Risk for Infection Impaired Skin Integrity 71

Lymphangitis Pathophysiology Acute inflammation of the lymphatic channels The inflammation is the result of an infectious process, usually caused by streptococcus 72

Lymphangitis Signs and symptoms Enlargement of the lymph nodes along the lymphatic channel Tenderness as these nodes are assessed Red streak from the infected wound extends up the extremity along the path of the lymphatics Elevated temperature and chills Where are the lymphatic nodes located? The infectious material can localize into an abscess with necrotic, suppurative discharge from the area. 73

Lymphangitis Medical diagnosis Classic signs and symptoms, supported by wound culture results Lymphangiography 74

Lymphangitis Medical and surgical treatment Antimicrobials Abscess is incised to drain the suppurative material Rest and elevation of the limb; warm, wet dressings; and elastic support hose 75

Lymphangitis Assessment Interventions Inspect skin for open wounds, inflammation, and red streaks along the paths of lymphatic channels Palpate lymph nodes in groin and underarm areas for enlargement Interventions Analgesics, antimicrobials, and elevation of the extremity to reduce lymphedema Application of warm, moist soaks to the infected areas Elastic support hose 76