Care of Patients with Vascular Problems Chapter 38 Care of Patients with Vascular Problems

Arteriosclerosis & Atherosclerosis Arteriosclerosis—thickening or hardening of arterial wall often associated with aging Atherosclerosis—type of arteriosclerosis involving formation of plaque within arterial wall Etiology and genetic predisposition

Atherosclerosis Pathophysiology of atherosclerosis.

Physical Assessment/Clinical Manifestations Monitor BP Palpate pulses in all major sites of body Assess for prolonged capillary refill Assess for bruit

Laboratory Assessment Lipid level, including cholesterol and triglycerides, elevated HDL and LDL High serum levels of homocysteine can allow cell walls to become vulnerable to plaque buildup

Interventions Evaluate total serum cholesterol levels and lifestyle changes Nutrition therapy Drug therapy Smoking cessation Exercise Complementary and alternative therapies

High-Risk Patients Diabetes without signs of vascular disease Framingham heart study with risk factor of >20% for CAD events Multiple metabolic risk factors

Drug Therapy HMG-CoA reductase inhibitors (statins) Fibrinic acids Ezetimibe (Zetia)

Hypertension Systolic blood pressure ≥140 and/or diastolic blood pressure ≥90 in people who do not have diabetes mellitus Patients with DM should have BP < 130/90 “Normal” adult systolic BP < 120; diastolic < 80

Essential Hypertension Results in damage to vital organs Causes medial hyperplasia (thickening) of arterioles Common risk factors: Obesity Smoking Stress Family history

Secondary Hypertension Common causes: Renal disease Primary aldosteronism Pheochromocytoma Cushing’s syndrome Medications

Assessment Patient history Physical assessment Psychological assessment Diagnostic assessment

Lifestyle Modifications Sodium restriction Weight reduction Reduced alcohol intake Exercise Decrease stress levels Avoid alcohol, smoking

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

Peripheral Arterial Disease (PAD) Alters natural flow of blood through arteries and veins of peripheral circulation Result of systemic atherosclerosis

Lower Extremity Arterial Disease Common locations of inflow and outflow lesions.

Physical Assessment Intermittent claudication Pain that occurs even while at rest; numbness and burning Inflow disease discomfort in lower back, buttocks, thighs Outflow disease burning or cramping in calves, ankles, feet, toes

Physical Assessment (cont’d) Hair loss and dry, scaly, pale or mottled skin, thickened toenails Severe arterial disease—extremity is cold and gray-blue or darkened; pallor may occur with extremity elevation; dependent rubor; and/or muscle atrophy

Diagnostic Assessments Imaging assessment Other: Ankle-brachial index (ABI) Exercise tolerance testing Plethysmography

Nonsurgical Management Exercise and positioning Promote vasodilation Drug therapy (antiplatelet agents) Percutaneous transluminal angioplasty Atherectomy

Surgical Management Preoperative Intraoperative Postoperative Deep breathing every 1-2 hr Monitor for graft occlusion (emergency) Treatment of graft occlusion Monitor for compartment syndrome Assess for infection

Aortoiliac and Aortofemoral Bypass In aortoiliac and aortofemoral bypass surgery, a midline incision into the abdominal cavity is required, with an additional incision in each groin.

Axillofemoral Bypass An axillofemoral bypass graft.

Six P’s of Arterial Insufficiency Pain Pallor Pulselessness Paresthesia Paralysis Poikilothermia (coolness)

Acute Peripheral Arterial Occlusion Embolus—most common cause of occlusions, although local thrombus may be cause May affect upper extremities but most common in lower extremities Drug therapy Surgical therapy Nursing care

Aneurysms of Central Arteries Aneurysm—permanent localized dilation of artery, enlarging artery to twice its normal diameter Types: Fusiform Saccular Dissecting (aortic dissection) Abdominal aortic Thoracic aortic

Arterial Aneurysms Common anatomic sites of arterial aneurysms.

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

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

Assessment of Thoracic Aortic Aneurysm Assess for back pain, manifestation of compression of aneurysm on adjacent structures Assess for shortness of breath, hoarseness, difficulty swallowing Mass may be visible above suprasternal notch Sudden excruciating back or chest pain symptomatic of thoracic rupture

Diagnostic Assessment X-ray “eggshell” appearance CT Aortic arteriography Ultrasonography

Nonsurgical Management Monitor aneurysm growth Maintain BP at normal level to decrease risk of rupture

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

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

Endovascular Repair of Abdominal Aortic Aneurysm For patients at high risk for major abdominal surgery Various designs Benefits Complications

Aortic Dissection May be caused by sudden tear in aortic intima, opening way for blood to enter aortic wall Pain described as tearing, ripping, stabbing Life threatening

Aortic Dissection (cont’d) Emergency care goals: Eliminate pain Reduce blood pressure Decrease velocity of left ventricular ejection Nonsurgical treatment Surgical treatment

Buerger’s Disease Thromboangiitis obliterans—relatively uncommon occlusive disease of arteries and veins in distal portion of upper and lower extremities Often identified with tobacco smoking Familial or genetic predisposition and autoimmune etiologic factors also possible

Buerger’s Disease (cont’d)

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

Raynaud’s Phenomenon Caused by vasospasm of arterioles and arteries of upper and lower extremities Drug therapy—nifedipine, cyclandelate, phenoxybenzamine Lumbar sympathectomy Restrict cold exposure Reinforce patient education

Raynaud’s Phenomenon (cont’d) Color changes of Raynaud’s phenomenon.

Venous Thromboembolism (VTE) Thrombus—a blood clot Thrombophlebitis Deep vein thrombosis (DVT) Pulmonary embolism Virchow’s triad Phlebitis

Assessment Calf or groin tenderness or pain Sudden onset of unilateral swelling of leg Checking Homans’ sign not advised Localized edema Venous flow studies—venous duplex ultrasonography MRI d-dimer

Nonsurgical Management Rest, preventive measures Drug therapy: Unfractionated heparin Low–molecular weight heparin Warfarin Thrombolytics

Surgical Management Thrombectomy Inferior vena caval interruption Ligation or external clips

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

Varicose Veins Distended, protruding veins that appear darkened and tortuous Collaborative care: Elastic stockings Elevation of extremities Sclerotherapy Surgical removal of veins Radio frequency energy to heat veins

Phlebitis Inflammation of superficial veins Management—warm, moist soaks; elastic stockings Complications—tissue necrosis, infection, pulmonary embolus

Vascular Trauma Punctures Lacerations Transections Assess for circulatory, sensory, motor impairment

A 58-year-old African-American man is visiting his health care provider for an annual check-up. His family history includes hypertension and type 2 diabetes. He is a cigarette smoker and is 30 pounds overweight. He works as a car salesman in a very competitive market. What are this patient’s risk factors for hypertension? This patient has several risk factors for hypertension including his age, being African American, having a positive family history for high blood pressure and diabetes, smoking, being overweight, and having job-related stress.

(cont’d) You check the patient’s vital signs with the following results: BP – 142/90 mm Hg HR – 86/min R – 8/min T – 97° F Based on these readings, does the patient have hypertension? Explain your response. The patient’s blood pressure indicates he may have stage 1 hypertension (see Table 38-3 in the text). However, blood pressure should be checked in both arms and two or more readings should be taken at each visit, with the average of the readings used as the value for the visit.

(cont’d) The patient is diagnosed with prehypertension. He asks you how this could happen since he feels fine. Which points do you include in your teaching plan? (Select all that apply.) Checking blood pressure only at the clinic to ensure accuracy Making lifestyle changes to control blood pressure Exercising and weight loss to decrease the need for BP medications Limiting smoking and caffeine to moderate use Alternative therapies such as relaxation techniques to help decrease stress associated with hypertension ANS: B, C, E Lifestyle changes, exercising, weight loss, and alternative therapies are all important components to successfully managing blood pressure. Part of the care plan should include teaching the patient to monitor his blood pressure on a daily basis, not just at his clinical visits. Smoking and caffeine intake should be avoided altogether.

(cont’d) At the end of the visit, the provider prescribes hydrochlorothiazide (HydroDIURIL) 25 mg PO each morning to manage the patient’s hypertension. Which statement do you include when teaching the patient about this drug? “This is a loop diuretic that decreases sodium reabsorption.” “HydroDIURIL is a potassium-sparing diuretic that helps prevent the loss of essential potassium.” “You may need to consume foods rich in potassium, such as bananas and orange juice.” “A potassium supplement will be prescribed along with this drug.” ANS: C Hydrochlorothiazide is a thiazide diuretic. The most frequent side effect is hypokalemia, so it’s important to teach patients the signs of low potassium, as well as which foods are rich in potassium. Some patients need a potassium supplement, but this is prescribed based on the patient’s serum potassium level.

Audience Response System Questions Chapter 38 Audience Response System Questions 55

Question 1 In older adults, which risk factor is a better indicator for heart disease and stroke? Resting heart rate of 82 beats/minute Blood pressure of 152/86 mm Hg Blood glucose of 120 mg/dL Blood pressure of 148/94 mm Hg Answer: B Rationale: Isolated systolic hypertension (SBP reading at or above 140 mm Hg with a DBP below 90 mm Hg) is a major risk factor for heart disease and stroke in older people (Safar et al., 2009). Blood glucose is on the high end of normal, and the heart rate is within normal limits, but on the high end for a resting heart rate.

Question 2 A patient with cardiovascular disease is prescribed a potassium-wasting diuretic. What food could the patient consume to help prevent hypokalemia? Baked potatoes Raw avocados Dried figs Red apples Answer: A Rationale: Many fruits, beans, and vegetables are high in potassium; however, a baked potato has approximately 1000 mg of potassium, an avocado has 180 mg, dried figs have 271 mg, and an apple has 160 mg. The patient should be encouraged to read nutrition labels for nutrient information as well. (Source: Accessed August 2, 2011, from http://www.fatfreekitchen.com/nutrition/potassium.html; and http://www.fda.gov/Food/default.htm)

Question 3 Annually in the United States, how many people are diagnosed with a venous thromboembolism? 100,000 300,000 600,000 900,000 Answer: C Rationale: The best estimates indicate that 350,000 to 600,000 Americans each year suffer from venous thromboembolism (deep vein thrombosis [DVT]) and pulmonary embolism [PE]), and that at least 100,000 deaths may be directly or indirectly related to these diseases. (Source: Accessed August 2, 2011, from http://www.surgeongeneral.gov/topics/deepvein/calltoaction/call-to-action-on-dvt-2008.pdf; http://www.apsfa.org/pesymptoms.htm)