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

2. 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

3. Atherosclerosis
Pathophysiology of atherosclerosis.

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

5. 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

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

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

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

9. 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

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

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

12. Assessment Patient history Physical assessment
Psychological assessment
Diagnostic assessment

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

14. 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

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

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

17. 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

18. 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

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

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

21. 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

22. 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.

23. Axillofemoral Bypass
An axillofemoral bypass graft.

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

25. 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

26. 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

27. Arterial Aneurysms
Common anatomic sites of arterial aneurysms.

28. 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

29. 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

30. 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

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

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

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

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

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

36. 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

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

38. 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

39. Buerger’s Disease (cont’d)

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

41. 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

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

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

44. 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

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

46. Surgical Management Thrombectomy Inferior vena caval interruption
Ligation or external clips

47. 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

48. 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

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

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

51. 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.

52. (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.

53. (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.

54. (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.

55. Audience Response System Questions
Chapter 38
Audience Response System Questions 55

56. 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.

57. 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 and

58. 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