Interventions for Clients with Vascular Problems

Arteriosclerosis and Atherosclerosis Arteriosclerosis: thickening or hardening of the arterial wall Arteriosclerosis: thickening or hardening of the arterial wall Atherosclerosis: type of arteriosclerosis involving the formation of plaque within the arterial wall Atherosclerosis: type of arteriosclerosis involving the formation of plaque within the arterial wall Etiology and genetic predisposition Etiology and genetic predisposition –Factors related to atherosclerosis include obesity, lack of exercise, smoking, and stress.

Laboratory Assessment Lipid level, including cholesterol and triglycerides, is elevated in atherosclerosis clients. Lipid level, including cholesterol and triglycerides, is elevated in atherosclerosis clients. High serum levels of homocysteine can allow cell walls to become vulnerable to plaque buildup. High serum levels of homocysteine can allow cell walls to become vulnerable to plaque buildup.

Interventions Evaluation of total serum cholesterol levels and lifestyle changes Evaluation of total serum cholesterol levels and lifestyle changes Diet therapy Diet therapy Smoking cessation Smoking cessation Exercise Exercise Drug therapy Drug therapy

Hypertension Hypertension: systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ to 90 mm Hg (not including diabetics) Hypertension: systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ to 90 mm Hg (not including diabetics) Malignant hypertension: elevated blood pressure that progresses rapidly to systolic pressure > 200 mm Hg and diastolic pressure > 130 mm Hg Malignant hypertension: elevated blood pressure that progresses rapidly to systolic pressure > 200 mm Hg and diastolic pressure > 130 mm Hg

Diseases Diseases that commonly cause secondary hypertension: Diseases that commonly cause secondary hypertension: –Renal vascular –Renal parenchymal –Dysfunction of the adrenal medulla or the adrenal cortex –Primary aldosteronism –Pheochromocytomas –Cushing’s syndrome –Coarctation of the aorta –Neurogenic disturbances, such as brain tumors, encephalitis, and psychiatric disturbances

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

Peripheral Arterial Disease Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation Manifestation of systemic atherosclerosis: a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients Manifestation of systemic atherosclerosis: a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients

Physical Assessment Intermittent claudication Intermittent claudication Pain that occurs even while at rest; numbness and burning Pain that occurs even while at rest; numbness and burning Inflow disease affecting the lower back, buttocks, or thighs Inflow disease affecting the lower back, buttocks, or thighs Outflow disease causing cramping in calves, ankles, and feet Outflow disease causing cramping in calves, ankles, and feet Hair loss and dry, scaly, mottled skin and thickened toenails Hair loss and dry, scaly, mottled skin and thickened toenails Ulcers: arterial ulcers, diabetic ulcers, venous stasis ulcers Ulcers: arterial ulcers, diabetic ulcers, venous stasis ulcers

Diagnostic Assessments Angiography Angiography Segmental systolic blood pressure measurements Segmental systolic blood pressure measurements Exercise tolerance testing Exercise tolerance testing Plethysmography Plethysmography

Nonsurgical Management Exercise Exercise Positioning Positioning Promoting vasodilation Promoting vasodilation Drug therapy Drug therapy Percutaneous transluminal angioplasty Percutaneous transluminal angioplasty Laser-assisted angioplasty Laser-assisted angioplasty Atherectomy Atherectomy

Surgical Management Preoperative care Preoperative care Operative procedures (bypass surgery) Operative procedures (bypass surgery) Postoperative care Postoperative care –Assessment for graft occlusion –Promotion of graft patency –Treatment of graft occlusion –Monitoring for compartment syndrome –Assessment for infection

Acute Peripheral Arterial Occlusion Embolus: the most common cause of occlusions, although local thrombus may be the cause Embolus: the most common cause of occlusions, although local thrombus may be the cause Assessment: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia Assessment: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia Drug therapy Drug therapy Surgical therapy Surgical therapy Nursing care Nursing care

Aneurysms of Central Arteries Aneurysm: a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter Aneurysm: a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter Fusiform aneurysm Fusiform aneurysm Saccular aneurysm Saccular aneurysm Dissecting aneurysm (aortic dissections) Dissecting aneurysm (aortic dissections) Thoracic aortic aneurysms Thoracic aortic aneurysms

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

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

Diagnosis and Management X-rays X-rays Computed tomography scan to assess size and location of aneurysm Computed tomography scan to assess size and location of aneurysm Aortic angiography Aortic angiography Ultrasonography Ultrasonography Goal of nonsurgical management: monitor growth of the aneurysm and maintain blood pressure at normal level Goal of nonsurgical management: monitor growth of the aneurysm and maintain blood pressure at normal level

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

Buerger’s Disease Thromboangiitis obliterans: relatively uncommon occlusive disease limited to the medium and small arteries and veins Thromboangiitis obliterans: relatively uncommon occlusive disease limited to the medium and small arteries and veins Often identified with tobacco smoking Often identified with tobacco smoking Nursing interventions to prevent progression of disease Nursing interventions to prevent progression of disease

Raynaud’s Phenomenon Caused by vasospasm of the arterioles and arteries of the upper and lower extremities Caused by vasospasm of the arterioles and arteries of the upper and lower extremities Drug therapy: Procardia, Cyclospasmol, and Dibenzyline Drug therapy: Procardia, Cyclospasmol, and Dibenzyline Lumbar sympathectomy Lumbar sympathectomy Reinforcement of client education; restriction of cold exposure Reinforcement of client education; restriction of cold exposure

Venous Thromboembolism Thrombus: a blood clot Thrombus: a blood clot Thrombophlebitis Thrombophlebitis Deep vein thrombosis Deep vein thrombosis Pulmonary embolism Pulmonary embolism High rate of death High rate of death

Assessment Calf or groin tenderness or pain Calf or groin tenderness or pain Sudden onset of unilateral swelling of the leg Sudden onset of unilateral swelling of the leg Positive Homans’ sign Positive Homans’ sign Localized edema Localized edema Venous flow studies Venous flow studies

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

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

Phlebitis Inflammation of the superficial veins Inflammation of the superficial veins Management: warm, moist soaks and elastic stocking Management: warm, moist soaks and elastic stocking Complications: tissue necrosis, infection, or pulmonary embolus Complications: tissue necrosis, infection, or pulmonary embolus