1. 1 Nursing Care & Interventions for Clients with Vascular Problems Keith Rischer RN, MA, CEN

2. 2 Today’s Objectives…  Review the pathophysiology of arteriosclerosis, including the factors that cause arterial injury  Discuss drug therapy for hypertension  Evaluate the effectiveness of interdisciplinary interventions to improve hypertension  Prioritize nursing care for the patient experiencing vascular disorders  Develop a continuing care plan for a client who has hypertension  Prioritize postoperative care for clients who have undergone peripheral bypass surgery.

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4. 4 Elsevier items and derived items © 2006 by Elsevier Inc.

5. 5 Atherosclerosis

6. 6 Atherosclerosis & Aging

7. 7 Serum Lipids:Cholesterol  One of the several types of fats (lipids) Important component of cell membranes, and bile acids Building blocks in certain types of hormones Predominant substance in atherosclerotic plaques  Circulates in the blood in combination with triglycerides, encapsulated by special fat-carrying proteins called lipoproteins  <200 is desirable for total cholesterol

8. 8 Lipoproteins LDL = Low Density Lipoproteins - “bad cholesterol”  <130 is desirable HDL = High Density Lipoproteins - “good cholesterol”  >30 is desirable- the higher the HDL, the lower the risk of CAD Triglycerides- combination of glycerol with 3 fatty acids  Transportable fuel- energy source  Strongly influenced by diet

9. 9 Cholesterol Levels  LDL Cholesterol  <100Optimal  100-129Near optimal/above optimal  130-159Borderline High  160-189High  >190Very high  Total Cholesterol  <200Desirable  200-239Borderline High  >240High  HDL Cholesterol  <40Low  >60High

10. 10 Elsevier items and derived items © 2006 by Elsevier Inc.

11. 11 Hypertension  “ Vascular Disease”  Affects 1 in every 4 adults in the US  Major risk factor for cardiovascular disease (CVD)  Stroke, MI, Heart Failure  Other Target Organ Damage  LV hypertrophy  Nephropathy  Vascular Disorders  PVD  Retinopathy

12. 12 Categories Primary (Essential)- without identified cause  90-95% of all hypertension  Pathophysiology: (exact cause unknown) Heredity H2O & Na+ retention Altered renin-angiotensin mechanism Stress and increase sympathetic nervous system activity Insulin resistance and hyperinsulinemia Endothelial cell dysfunction Secondary- results from identifiable cause  renal disease, endocrine disorders, neuro disorders, meds, PIH

13. 13 Stages of Hypertension CategorySBP(mmHg)DBP(mmHg)  Normal<120<80  Prehypertension120-13980-89  Hypertension, Stage 1: 140-15990-99  Hypertension, Stage 2: 160-179100-109  Hypertension, Stage 3: >180>110

14. 14 Clinical Manifestations Early  Elevated BP  Asymptomatic (silent killer) Later  Symptoms secondary to effects on blood vessels in various organs or tissues Fatigue, reduced activity tolerance, dizziness, palpitations, angina, dyspnea

15. 15 Risk Factors for Primary Hypertension  Age  Alcohol use  Cigarette smoking  DM  Elevated serum lipids  Excess dietary sodium  Gender  Family history  Obesity  Ethnicity  Sedentary lifestyle  Socioeconomic status  Stress

16. 16 Knowledge Deficit  Encourage healthy lifestyles  Lifestyle modifications for all patients with prehypertension and hypertension  Components of lifestyle modifications include:  weight reduction,  DASH eating plan  dietary sodium reduction  aerobic physical  activity  moderation of alcohol consumption  Stress reduction

17. 17 Risk for Ineffective Therapeutic Regimen Management  Interventions:  Teach medication compliance, usually for the rest of life. goals of therapy potential side effects  Assist client to understand therapeutic regimen.  Discuss consequence of noncompliance  Most African American clients will need at least 2 medications to achieve blood pressure control ACE inhibitor and calcium channel blocker.

18. 18 Diuretics  Loop  Bumetanide (Bumex)  Furosemide (Lasix)  Thiazide-Type  Chlorothiazide  Hydrochlorothiazide (HCTZ)  Potassium-Sparing  Spironolactone (aldactone)

19. 19 Pharmacologic: Diuretics  Mechanism of Action:  Thiazides, Loop, Potassium Sparing  S/E: fluid and electrolyte imbalances –K+, Mg++ CNS effects GI effects  Nursing Considerations: Monitor for orthostatic hypotension –dehydration Hypokalemia

20. 20 Adrenergic Inhibitors: Beta Blockers  Cardioselective (β 1 )  Atenolol (Tenormin)  Metoprolol (Lopressor)  Non-cardioselective (β 1, β 2 )  Propranolol (Inderal)  Mechanism of Action  Blocks beta actions causing: decreased heart rate decreased BP decreased contractility

21. 21 Adrenergic Inhibitors: Beta Blockers  S/E: Orthostatic hypotension Bradycardia Hypotension Fatigue Weakness  Nursing considerations Use in caution with heart failure Diabetes who take BB may not have sx of hypoglycemia monitor pulse regularly

22. 22 Angiotensin Converting Enzyme (ACE) Inhibitors Captopril (Capoten) Enalapril (Vasotec) Lisinopril (Prinivil) Mechanism of Action  S/E:  Hypotension  cough  Hyperkalemia…esp w/CHF, CKD, DM  Angioedema Facial/laryngeal swelling  Nursing considerations:  Do not use with potassium sparing diuretic  Metabolized by liver-excreted by kidneys

23. 23 ACE Inhibitors  Drug Interactions:  NSAIDS (decrease BP control)  Diuretics (excessive hypotensive effect)  Potassium supplements, potassium-sparing diuretics (increased risk of hyperkalemia)  Lithium (increased lithium serum levels)  Precautions:  “First dose effect “– severe hypotension. Remain in bed for 3 to 4 to prevent falls.  Obtain BP before giving - hold if hypotensive  Change positions slowly due to orthostatic hypotension  Monitor liver and kidney function

24. 24 Angiotensin Receptor Antagonists (Blockers) Losartan (Cozaar)  Mechanism:  Inhibit binding of angiotensin II receptors in blood vessels and other tissues vascular smooth muscle relaxation increased salt and water excretion reduced plasma volume  Side Effects:  Hypotension  Dizziness  Cough,  Heart failure  Angioedema  Drug Interactions:  Potassium-sparing diuretics (  serum K + )

25. 25 Calcium Channel Blockers Amlodipine (Norvasc) Diltiazem (Cardizem) Nifedipine (Procardia)  Mechanism of Action  Blocks slow channels of Calcium Decreases contractility Vasodilation AV node slows

26. 26 Calcium Channel Blockers  S/E:  Hypotension  Bradycardia  AV block  Nausea  H/A  Peripheral edema Monitor I&O closely  Nursing considerations:  Always obtain BP-HR before giving  use with caution in patients with heart failure  Orthostatic changes Change position slowly  contraindicated in patients with 2 nd or 3 rd degree heart block  Concurrent use w/b-blockers incr risk of CHF

27. 27 HTN Case Study  45yr African American male  Complaint: new onset severe global HA  VS: P-88 R-20 BP-210/142 sats 96% RA Slightly confused to place, time  PMH: HTN x10 yrs-unable to afford meds, not taking the last week  Labs: K+ 4.2, Na+ 138, creat 2.5, trop neg, 12 lead EKG no acute changes  Nursing/medical priorities…

28. 28 HTN Case Study  MD orders:  Metoprolol 5mg IV push q5” x3 for SBP 160- 180  5mg/5cc….administer over 2”…how much every 15-30 seconds??? Nursing priorities/considerations…  Admit to ICU  VS before transfer: P-68 R-20 BP-192/118

29. 29 In ICU…  Started on Nipride gtt  Started at 0.5mcg  BP 180/90….in 2 hours  Next am 140/90  Started on po:  Lisinopril  Diltiazem  Metoprolol Concerns to address upon DC???

30. 30 Peripheral Arterial Disease  Altered flow of blood through arteries/veins of peripheral circulation  Manifestation of systemic atherosclerosis  a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients

31. 31 Physical Assessment  Intermittent claudication  Pain that occurs even while at rest; numbness and burning  Inflow disease affecting the lower back, buttocks, or thighs  Distal aorta  Outflow disease causing cramping in calves, ankles, and feet  Superficial femoral artery (knee and down)  Hair loss and dry, scaly, mottled skin and thickened toenails  Ulcers  arterial ulcers  diabetic ulcers  venous stasis ulcers.

32. 32 Nonsurgical Management  Exercise  Positioning  avoid extreme raising legs above heart, do elevate for edema  Promoting vasodilation  warmth and avoid cold temp, stop smoking  Drug therapy  clopidogrel (Plavix), Pentoxifylline (Trental), ASA  Percutaneous transluminal angioplasty  Atherectomy.

33. 33 Surgical Management  Preoperative care  Documentation of distal pulses  Postoperative care  Assessment for graft occlusion  Promotion of graft patency  Treatment of graft occlusion  Monitoring for compartment syndrome  Assessment for infection.

34. 34 Acute Peripheral Arterial Occlusion  Embolus  most common cause of occlusions, although local thrombus may be the cause  Assessment  pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (coolness)  Surgical therapy  arteriotomy  Nursing care  CMS  Pain assessment  Spasms/swelling Compartment syndrome.

35. 35 Anticoagulation Therapy:Heparin  Inhibits (does not dissolve) thrombus and clot formation  Given IV/SQ Never given IM D/T risk of hematoma  Does not cross placental barrier  Antidote Protamine sulfate: Fast acting, short ½ life  Note: If sx’s of bleeding stop infusion, be prepared to give antidote

36. 36 Aneurysms of Central Arteries  Patho  Middle layer weakened  Stretching of intima  Fusiform aneurysm  Saccular aneurysm  Dissecting aneurysm (aortic dissections)  Thoracic aortic aneurysms  Abdominal aortic aneurysms.

37. 37 Thoracic & Abdominal Aortic Aneurysm  Thoracic  Back pain  shortness of breath hoarseness, and difficulty swallowing  Sudden excruciating back or chest pain is symptomatic of thoracic rupture  Abdominal  Pain steady with a gnawing quality unaffected by movement-may last for hours or days abdomen, flank, or back.  Abdominal mass is pulsatile  Rupture is the most frequent complication and is life threatening.

38. 38 Aortic Dissection  Patho  Pain  Emergency care goals include:  Elimination of pain  Reduction of blood pressure  Immediate OR  Surgical treatment

39. 39 Abdominal Aortic Aneurysm Repair  Preoperative care  Assess peripheral pulses  Operative procedure  Postoperative care  Monitor vital signs  Assess for complications Paralytic ileus  Assess for graft occlusion or rupture Change in CMS Severe pain Decreased u/o.

40. 40 Thoracic Aortic Aneurysm Repair  Preoperative care  Operative procedure  Postoperative care assessments:  Vital signs  CMS changes  Complications Respiratory distress Cardiac dysrhythmias Hemorrhage Paraplegia.

41. 41 Raynaud’s Phenomenon  Patho  Sx  Blanching >cyanosis  Pain Aggravated by cold/stress  Treatment  Procardia Side effects  Education  Cold exposure  Stop smoking  Stress reduction.

42. 42 Venous Thromboembolism  Thrombus  Virchows Triad Venous blood stasis Endothelial injury hypercoagubility  Thrombophlebitis  Thrombus w/inflammation  Deep vein thrombosis (DVT)  Pulmonary embolism  Phlebitis  Inflammation of superficial veins  Assessment:  Calf or groin tenderness or pain  Sudden onset of unilateral swelling of the leg  Localized edema  Venous flow studies-US  Lab:D-Dimer.

43. 43 Nonsurgical Management  Treatment Priorities  Prevent complications  Rest  Drug therapy includes:  Heparin IV therapy  Low–molecular weight heparin-Subq Lovenox q 12 hours  Warfarin therapy  Thrombolytic therapy TPA

44. 44 Surgical Management

45. 45 Venous Insufficiency  Patho  Sx  Edema TEDS  Stasis dermatitis  Stasis ulcers Occlusive dressings.