Unit 2Diseases of Blood

Vessels

Hypertension

•High Blood Pressure•Most common CV problem in US today

•Persistent BP readings > or = 140/90

HTN

•Silent killer – why?•Incidence – men vs. women; African American

•Increasing in children

HTN•2 factors determine BP

–Cardiac Output–Peripheral Vascular Resistance

–BP = CO X PVR

HTN Complications:

•Damage to:–Heart–Blood Vessels–Kidneys–Brain–Eyes

Types of HTN

•Primary (Essential)•Secondary•Malignant

Primary or Essential

•90-95% of cases•Cause unknown

Secondary•Known cause•Kidney disease, tumors, malformed blood vessels, endocrine problems

•Pregnancy

Malignant

•Sudden•Rapid progression•Inc in black males < 40•Usually fatal within 2 years

Risk Factors HTN

•Dyslipidemia•Atherosclerosis•Diabetes•Smoking•> 60 y.o.•Male

Risk Factors HTN

•Postmenopausal female

•Family History •Sedentary Lifestyle•Obesity•Others

Signs and Symptoms

•Usually no early s/s - “silent killer”•Occipital headaches•Lightheadedness•Epistaxis

Signs and Symptoms

•Fatigue•Dyspnea•Edema•Nocturia•Organ Damage

Treatment Goal

•Reduce PVR and BP•Treat Underlying Conditons

Lifestyle Modification

•Weight loss•Smoking Cessation•Na and Alcohol restriction

•Exercise•Relaxation

Pharmacologic•Stepped Care Approach

–Step 1 – start 1 drug•Thiazide diuretic•Betablocker•ACE inhibitor•Calcium Channel Blockers

Pharmacologic–Step 2

•Increase dose of first drug or add 2nd

–Step 3•Increased dose, add 3rd drug, try different drug from step 1

Pt Education

•Lifelong treatment•Meds•Lifestyle changes

(CVA) Cerebrovascular

Accident

•Interruption of blood flow to part of brain

•What happens then?

CVA

•3rd leading cause of death in U.S.

•Leading cause of adult disability

Types of Stokes

•Hemorrhagic•Ischemic

Hemorrhagic Stroke•20% of all strokes•Blood vessel ruptures or bleeds

•Classified by location–Intracerebral–Subarachnoid

Ischemic Stroke•80% of all strokes•Caused by obstruction of blood vessel

•Classified as:–Embolic–Thrombotic

NonmodifiableRisk factors

•Age•Race•Gender •Heredity

ModifiableRisk factors

•Refer to Table 27-1–Page 410

Diagnosis•H & P•Brain Imaging Studies

–Angiography–Doppler Studies–CT / MRI–EEG

Stages of a Stroke•TIA

–Transient Ischemic Attack

•SIE–Stroke In Evolution

•CS–Complete Stroke

Transient Ischemic Attack (TIA)

•Temporary Neurological Deficit

•Last few minutes to 24 hours

•No permanent effects

TIA Treatment•Platelet Aggregatin Inhibitors–Examples?

•Anticoagulants–Examples?

TIA Treatment

•Carotid Endarterectomy

•Angioplasty

Complete Stroke (CS)

•When neuro deficits do not change for 2 – 3 days

CVA•Recovery is uncertain at first

•Brain cells do not regenerate

•If damaged but not dead, do have potential

CVA•Collateral circ plays role•Cell damage also d/t edema in brain

•Quick functional return = better prognosis

As Health Care Professional:

•Recognize impending CVA warning signs

•Get help ASAP•New therapies can prevent/dec damage

- TPA or Amicar

Signs and Symptoms

•Depend on: - Cause - Area of brain affected

Hemorrhagic Stroke

•Sx. Generally sudden•Severe headache•Stiff neck•Loss of consciousness•Vomiting•Seizures

Embolic Stroke•Sx. usually occur without warning

•May see hx. of heart or blood vessel disease

•Many possible S & S–WHY?

Thrombotic Stroke

•Sx. can be gradual or sudden onset

•Sx. related to area affected

Brain Damage S/S

•AphasiaAphasia•DysarthriaDysarthria•DysphagiaDysphagia•DyspraxiaDyspraxia•HemiplegiaHemiplegia

–Most common result

•Sensory ImpairmentSensory Impairment•Unilateral NeglectUnilateral Neglect•Homonymous Homonymous HemianopsiaHemianopsia

•Intellectual/EmotionalIntellectual/Emotional•EliminationElimination

CVA Nursing Implications

L.O.C.•Neuro Check q1h - Glasgow Coma Scale•Get baseline assess•Report and document change in LOC ASAP

Motor & Sensory Functions

•Compare bilaterally

The Acute PhaseThe Acute Phase

Medical Tx of CVA

•Depends on symptoms•Treat HTN•Treat increased ICP

Airway / OxygenAirway / Oxygen•Position on unaffected side•Monitor O2 Sat. (pulse ox.)•Oral airway available•Suction equip in room•O2 in room

Frequent Vitals and Frequent Vitals and Neuro checksNeuro checks

•Check for s/s of inc ICP•If see s/s of inc ICP, elevate HOB 30º

S/S of Inc. ICP(Intracranial pressure)

•Change in LOC•Change in Sensory, Motor Function

•Pulse <60, >100•Resp Distress•Widened pulse press.•Pupil changes

Drug TherapyDrug Therapy•tPA if ischemic

–Within 3 hours•Treat Cerebral Edema

–Diuretics–Corticosteroids

•Treat Hypertension

Rehabilitation Phase

•Affected by acute Nursing care

•Prevent contractures•Prevent decubs and joint deformities

•B & B training

Goal of Rehab

•Return > independence•As much self care as possible

•Eval ability to perform self care first

Rehab disciplines

•Nursing•Physicians•P.T., O.T., S.T.•Social service•Dietician

Ms. Sandusky is an 82yo female brought into ER forcomplaints of right sided weakness and visual disturbances.

Past History: Multiple TIA’s, HTN, and NIDDM.Surgical History: RTHA, Laminectomy.Social History: No smoking, occasional ETOH use. Lives

alone. No family in area. NKDAMeds: Lotrel 10mg daily, ASA 81mg daily, Glucophage

1000mg 2xday, Percocet PRN, Xanax PRN

Current: 178/92, 102, 18, 98.9, 98%. Begin Heparin dripper protocol NOW, Clonodine 1mg po NOWPt flaccid right side. Dyspraxia noted. ST to evalfor dysphagia. Pt aphasic. Continue home meds.May crush in thickened liquids

Diseases of the Arteries

Arterial Embolism•Blood clot carried through circulation

•Often arise from chambers of heart

•Esp with atrial fib, MI, CHF, endocarditis

S/S:•Severe, acute Pain•Gradual loss of sensory and motor function

•Pain with movement•Absent Pulses•Pallor or mottling•Temp Change

Management•Anticoagulants•Thrombolytics•Embolectomy - surgical removal of clot•Patient Education

Peripheral Arterial Occlusive Disease

•Atherosclerosis obliterans

•Arterial Insufficiency•Peripheral Vascular Disease (PVD)

Peripheral Arterial Occlusive Disease

•Increased in men •Cause:

–Atherosclerosis–Embolism–Trauma–Vasospasm

Risk Factors:

•Cigs•Hyperlipidemia•HTN•DM•Stress

Hallmark symptom:•Intermittent claudicationIntermittent claudication–pain in lower extrem.

•Aching, cramping,•Tiredness, weaknesss

with exercise, rest

Other S/S:•Diminished / Absent Peripheral Pulses

•Rest pain•Numbness / Tingling•Coolness•Muscle Atrophy

Other S/S:•Skin Changes

–Pale when up–Red with dependency–Hairlessness

•Nail Changes

Diagnosis

•Doppler studies•Plethymography•Angiography

Treatment

•Decrease risk factors•Drug therapy•Surgery

Types of surgery

•Sympathectomy•Vascular grafting•Endarterectomy•PTA (Percutaneous Transluminal Angioplasty)

•Amputation

Nursing Care•Assess: - peripheral pulses - color - temp - mobility- sensation (peripheral

neuropathy ?)

Nursing Care•Protect from Injury

–no pressure–foot care–shoes/socks–careful w/ temp. extremes

–no leg crossing

Nursing Interventions:

•Activity Intolerance•Pain•Impaired Skin Integrity•Ineffective Tissue Perfusion

•Risk for Infection

Buergers Disease•Thromboangiitis Obliterans•Inflammatory thrombotic disorder of arteries and veins in LE and UE

•Results in obstruction/occlusion

Buergers Disease•Not atherosclerotic process

•Cause Unknown•Occurs only in smokers

Symptoms•Intermittent claudication

•Rest Pain•Skin color & temp changes

Symptoms

•Cold Sensitivity•Abnormal sensation•Ulceration•Gangrene

Treatment•Smoking Cessation•Buerger-Allen Exercises

–See pg. 617-618•Vasodilators•Antibiotics

Treatment•Anticoagulants •Platelet Aggregation Inhibitors

•Protection of Affected Extremities

•Sympathectomy

Raynaud’s Disease

•Intermittent arteriolar vasoconstriction

•Affects Hands Primarily•Inc in women 16 - 40

S/S:•Chronically Cold hands, Numbness, Tingling and Pallor.

•Not symmetric•Skin Changes:

–Pallor to cyanosis to redness

Treatment

•Prevent Pain–Avoid stimuli that causes vasoconstriction

–Ideas???

Treatment:

•Promote Vasodilation–Ca Channel Blockers–ACE inhibitors–Alpha Blockers–Sympatholytics

Aneurysms•Dilated segment of an artery

•Due to weakness and stretching of arterial wall

http://www.healthline.com/channel/abdominal-aortic-aneurysm-aaa_videos

Causes:•Congenital•Aquired

–Arteriosclerosis (athero)–Trauma–Infection–Hypertension

Location

•Aorta–Abdominal

•Most common site•Thoracic

S/S:•Vary with location•Thoracic

–Often without sx.–Chest pain–Hoarseness–Dysphagia

S/S:•Abdominal

–Most asymptomatic –Usually detected on Routine PE and X-Ray

–Back/Flank PainBack/Flank Pain–Epigastric Pain–Constipation

Complications•Rupture•Thrombus Formation•Emboli•Pressure on Surrounding Structures

Treatment•Control systolic BP - i.e.- Captopril•Surgery (~ 5 cm.) - synthetic graft

Postop Care•Impaired Urinary Elimination

•Risk for Injury•Ineffective Breathing Pattern

Postop Care•Decreased Cardiac Output

•Ineffective Tissue Perfusion

Cerebral Aneurysm•Localized vascular dilatations

•Most result from congenital defects

•Also from head injury•Bifurcation of major art

Rupture of cerebral aneurysm

•Hemorrhagic CVA•May be fatal•Most have hx of HTN•Activity often precedes

Nursing Care:•Prevent rebleeding•Keep quiet as possible•Look for change in LOC - Glasgow coma scale•Inc ICP or BP > inc rebleed

Glasgow Coma Scale

•Eye opening response

•Speech•Motor ability

Surgical Tx of Cerebral Aneurysm

•Tx of choice•Clipping•Reinforce with muscle fascia or acrylic

Diseases of the VeinsDiseases of the Veins

VenousVenous ThrombosisThrombosis•Includes:

–PhlebitisPhlebitis–ThrombophlebitisThrombophlebitis–PhlebothrombosisPhlebothrombosis–Deep Vein Deep Vein Thrombosis (DVT)Thrombosis (DVT)

3 Contributing Factors•Called Virchow’s Triad

–Stasis of blood–Damage to the vessel walls

–Hypercoagulability

Risk Factors

BedrestSurgery (general anesthesia) > 40

Leg Trauma and Immobiization

Risk Factors contPrevious Venous Insufficiency

ObesityOral ContraceptivesMalignancy

SymptomsOften AsymptomaticEdemaWarmthTenderness / PainWith DVT: + Homan’s Sign+ Homan’s Sign

Diagnosis

VenographyPlethysmographyDoppler Ultrasound

Treatment Goal:

Prevent thrombosisPrevent PEPrevent recurrenceReduce Discomfort

Treatment cont:•Anticoagulant Therapy:

–IV Heparin–Oral Coumadin

•Thrombolytic therapy•Surgical thrombectomy

Nursing Care:•Ongoing assess for PE•Bedrest•Elevation of extremity•Antiembolism Hose•Warm, Moist soaks

Nursing Care

Compare extremitiesProtect from pressureAnalgesics as prescribedPt. Education

Pt Education re: anticoagulants

Take daily - same timeWear medical ID bandBl testing importanceDrug interactionsS/S of bleedingAvoiding injury

Chronic Venous Insufficiency

•Culmination of long standing venous hypertension

•Veins and Valves are damaged

Symptoms:•Edema (ankles)•Stasis dermatitis•Stasis ulceration

–Medial Malleolus•Pain with dependency and ambulation

Symptoms:Pain in Calf or thigh

–Heaviness/Dull acheSkin CoolPulses present

–May be difficult to palpate – WHY?

Treatment Goal

•Promote venous return

•Prevent / Treat Ulceration

Nursing Interventions•Ineffective Tissue PerfusionIneffective Tissue Perfusion

–Elevate legs–Avoid

•Standing still•Crossing legs•Restrictive clothing

Nursing Interventions

•Disturbed Body Image•Risk for Infection

–Monitor for infection–Handwashing–Wound care

Nursing Interventions

•Impaired Skin Integrity–Checking / Treating ulcerations

–Teaching home care

Leg Ulcers:

•Major complication with PVD

•Prevention is key•Good nursing assess•Good pt education

Varicose Veins

•Dilated, tortuous superficial veins

•D/T incompetent valves•Usually in LE•Affects 1 in 5 people

Result of:•Hereditary weakness•Aging•Pregnancy•Obesity•Prolonged Standing

Symptoms:•Oversized, Discolored, Tortuous Veins

•Dull aching •Heaviness•Muscle Cramps

–Increased at night

Symptoms:•Muscular Fatigue•Ankle Edema•Over time

–Postphlebotic Syndrome

Diagnosis•Plethysmography•Venogram•Doppler Ultrasound•Brodie-Trendelenberg

Treatment•Medical

–Avoid •Restrictive garments•Prolonged standing or sitting

•Crossing Legs

Treatment–Elevate Extremity–Weight Reduction–Support Stockings

•Surgery–Sclerotherapy–Ligation and Stripping

Surgical management

•Vein ligation (tied off) and stripping (removal)

•Other veins take over work of those removed

Nursing care after ligation and stripping

•Pt education•Elastic compression•Exercise legs•Elevate foot of bed•Early ambulation•Discharge teaching

A woman, calling Mount Sinai Hospital, said, "Hello, I want to know if a patient is getting better."The voice on the other end of the line said, "Do you know the patient's name and room number?"She said, "Yes, darling! She's Sarah Finkel, in Room 302."He said, "Oh, yes. Mrs. Finkel is doing very well. In fact, she's had two full meals, her blood pressure is fine, she's going to be taken off the heart monitor in a couple of hours and if she continues this improvement, Dr. Cohen is going to send her home Tuesday."The woman said, "Thank God! That's wonderful! Oh! That's fantastic! That's wonderful news!"The man on the phone said, "From your enthusiasm, I take it you must be a close family member or a very close friend!"She said, "I'm Sarah Finkel in 302! Cohen, my doctor, doesn't tell me a word!"