Indezine Template

Chapter 38
Care of Patients with Vascular Problems
Mrs. Marion Kreisel RN, MSNNU230 Adult Health 2Fall 2011

Arteriosclerosis and Atherosclerosis
Arteriosclerosisthickening or hardening of the arterial wall often associated with aging.Atherosclerosistype of arteriosclerosis involving the formation of plaque within the arterial wall.Etiology and genetic predisposition:Factors related to atherosclerosis include obesity, lack of exercise, smoking, and stress.

Atherosclerosis

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

Interventions
Evaluation of total serum cholesterol levels and lifestyle changesNutrition therapySmoking cessationExerciseNational Cholesterol Education Program (NCEP)Therapeutic Lifestyle Change (TLC) diet

Drug Therapy
HMG-CoA reductase inhibitors (statins)Fibrinic acidsZetiaOmacar

Hypertension
Hypertensionsystolic blood pressure 145 mm Hg and/or diastolic blood pressure 90 mm Hg in people who do not have diabetes mellitus.Patients with DM should have a BP below 130/90.Normal adult systolic BP less than 120; diastolic less than 80.

Hypertension (Contd)
Prehypertensive systolic 120 to 139 and diastolic 80 to 89.Isolated systolic hypertension.Malignant hypertension is a severe type of elevated BP that rapidly progresses.

Essential Hypertension
Age greater than 60 yearsFamily history of hypertensionExcessive calorie consumptionPhysical inactivityExcessive alcohol intakeHyperlipidemiaAfrican-American ethnicityHigh intake of salt or caffeine

Essential Hypertension (Contd)
Reduced intake of K, Ca, or MgObesitySmokingStressMonitor for increase in BUN (10-20mg.d/L) and Serum Creatinine (0.5-1.2mg/dL) Levels

Secondary Hypertension
Renal diseasePrimary aldosteronismPheochromocytomaCushings syndromeMedications

Assessment
Patient historyPhysical assessment Psychological assessmentDiagnostic assessment

Knowledge Deficit
Interventions include:Sodium restrictionWeight reductionModeration of alcohol intakeExerciseRelaxation techniquesTobacco and caffeine avoidance

Drug Therapy
Diuretics: 3 basic types used to decrease b/pThiazides: hydrochlorothiazide (HydroDIURIL, Urozide. Promote NA+ & K+ excreationLoop: Furosemide (Lasix) promote Na+ & K+ excreationK+ Sparing: spironolactone(Aldactone, Novospiroton) inhibits Na+ reabsorption and retains K+Calcium channel blockers: Verapamil hydrochloride (Calan) & amlodipine (Norvasc) VasodilationACE inhibitors: captopril (Capoten) & enalapril (Vasotec). decrease vasoconstriction and control B/P (cough)VERY IMPORTANT EDUCATION ABOUT MEDS!WATCH FOR OTROSTATIC HYPOTENSION!

Drug Therapy Continued
Angiotensin II receptor antagonists: Aldosterone receptor antagonistsBeta-adrenergic blockers: drug of choice for patients with ischemic heart disease. Renin inhibitors: new category of drugs mild to moderate HTN enzyme produced by kidneys to cause vasoconstriction therefore they inhibit that mechanismCentral alpha agonistsAlpha-adrenergic agonists

Risk for Ineffective Therapeutic Regimen Management
Interventions include:Teach medication compliance, usually for the rest of life.Discuss goals of therapy, potential side effects, and how to identify potential problems.Assist patient to understand therapeutic regimen.Discuss consequence of noncompliance.

Peripheral Arterial Disease
Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation. Extreme lose of feeling can occur so pt education very importantCan lead to a DVT. Pt will be on anticoagulation therapy and will need lots of pt education.

Lower Extremity Arterial Disease

Physical Assessment
Intermittent claudicationPain that occurs even while at rest; numbness and burningInflow disease discomfort in the lower back, buttocks, or thighsOutflow disease burning or cramping in the calves, ankles, feet, and toes

Physical Assessment (Contd)
Hair loss and dry, scaly, pale or mottled skin and thickened toenailsSevere arterial diseaseextremity is cold and gray-blue or darkened; pallor may occur with extremity elevation; dependent rubor; and/or muscle atrophy

Diagnostic Assessments
Imaging assessmentOther diagnostic tests:Ankle-brachial index (ABI)Exercise tolerance testingPlethysmography

Nonsurgical Management
ExercisePositioningPromoting vasodilationDrug therapyPercutaneous transluminal angioplastyLaser-assisted angioplastyAtherectomy

Surgical Management
Aortoiliac and aortofemoral bypass surgery

Axillofemoral Bypass Graft

Surgical Management
PreoperativeIntraoperative

Surgical Management (Contd)
Postoperative care:Assessment for graft occlusionPromotion of graft patencyTreatment of graft occlusionMonitoring for compartment syndromeAssessment for infection

Acute Peripheral Arterial Occlusion
Embolusthe most common cause of occlusions, although local thrombus may be the causeAssessmentpain, pallor, pulselessness, paresthesia, paralysis, poikilothermiaDrug therapySurgical therapyNursing care

Aneurysms of Central Arteries
Aneurysma permanent localized dilation of an artery, enlarging the artery to twice its normal diameterFusiform aneurysmSaccular aneurysmDissecting aneurysm (aortic dissection)Abdominal aortic aneurysm Thoracic aortic aneurysm

Arterial 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 is in the abdomen, flank, or back.Abdominal mass is pulsatile.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 shortness of breath, hoarseness, and difficulty swallowing.Occasionally a mass may be visible above the suprasternal notch.Sudden excruciating back or chest pain is symptomatic of thoracic rupture.PLAN FOR IMMEDIATE SURGERY TO SAVE PT LIFE!

Diagnostic Assessment
X-ray eggshell appearance CTAortic arteriographyUltrasonography

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

Abdominal Aortic Aneurysm Resection
Preoperative careOperative procedurePostoperative care:Monitor vital signsAssess for complications such as decrease u/o. If this happens MD will order kidney function testsAssess for signs of graft occlusion or rupture

Thoracic Aortic Aneurysm Repair
Preoperative careOperative procedurePostoperative care assessments:Vital signsComplicationsSensation and motion in extremitiesRespiratory distressCardiac dysrhythmias

Endovascular Repair of Abdominal Aortic Aneurysm
Patients selected for endovascular repair are generally at high risk for major abdominal surgeryVarious designsBenefits of endovascular repairComplications of endovascular repair

Aneurysms of the Peripheral Arteries
Femoral and popliteal aneurysmsSymptomslimb ischemia, diminished or absent pulses, cool to cold skin, and painTreatmentsurgeryPostoperative caremonitor for pain

Aortic Dissection
May be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wallPain described as tearing, ripping, and stabbing

Aortic Dissection (Contd)

Aortic Dissection (Contd)
Emergency care goals include:Elimination of painReduction of blood pressure Decrease in the velocity of left ventricular ejectionNonsurgical treatmentSurgical treatment

Buergers Disease
Thromboangiitis obliteransrelatively uncommon occlusive disease limited to the medium and small arteries and veinsOften identified with tobacco smoking Nursing interventions

Buergers Disease (Contd)

Other Disorders
Subclavian steal occurring from artery occlusion or stenosisThoracic outlet syndrome resulting in arterial wall damagePopliteal entrapment

Raynauds Phenomenon
Caused by vasospasm of the arterioles and arteries of the upper and lower extremitiesDrug therapyProcardia, Cyclospasmol, and DibenzylineLumbar sympathectomyReinforcement of patient education; restriction of cold exposure

Raynauds Phenomenon (Contd)

Venous Thromboembolism
Thrombusa blood clotThrombophlebitisDeep vein thrombosis (DVT)Pulmonary embolismVirchows triadPhlebitis

Assessment
Calf or groin tenderness or painSudden onset of unilateral swelling of the legChecking Homans signnot advisedLocalized edemaVenous flow studiesvenous duplex ultrasonographyMRID-dimer

Nonsurgical Management
Rest, drug therapy, preventive measuresDrug therapy includes:Unfractionated heparin therapyLowmolecular weight heparinWarfarin therapyThrombolytic therapy

Surgical Management
ThrombectomyInferior vena caval interruptionLigation or external clips

Venous Insufficiency
Result of prolonged venous hypertension, stretching veins and damaging valvesStasis dermatitis, stasis ulcersManagement of edemaManagement of venous stasis ulcersDrug therapySurgical management

Varicose Veins
Distended, protruding veins that appear darkened and tortuousCollaborative management includes:Elastic stockingsElevation of extremitiesSclerotherapySurgical removal of veinsRadio frequency energy to heat the veins

Phlebitis
Inflammation of the superficial veinsManagementwarm, moist soaks and elastic stockingComplicationstissue necrosis, infection, or pulmonary embolus

Vascular Trauma
PuncturesLacerationsTransectionsAssess for circulatory, sensory, or motor impairment

NCLEX TIME

Question 1
How many adults in the United States have one or more types of cardiovascular disease?

22 million41 million62 million81 million

Question 2
A patient with atherosclerosis and type 2 diabetes mellitus has these laboratory results. Which one is of most concern for this patient?

Total serum cholesterol level of 205 mg/dL Low-density lipoprotein cholesterol (LDL-C) level of 98 mg/dL High-density lipoprotein cholesterol (HDL-C) level of 42 mg/dL Triglyceride level of 150 mg/dL

Question 3
A normal adult blood pressure would be:

100 to 110 mm Hg systolic or 60 to 79 mm Hg diastolic Less than 120 mm Hg systolic and less than 80 mm Hg diastolic 120 to 139 mm Hg systolic and 80 to 89 mm Hg diastolic Less than 140 mm Hg systolic and less than 90 mm Hg diastolic

Question 4
Which type of antihypertensive drug is considered the drug of choice for hypertensive patients who also have ischemic heart disease?

Thiazide diuretics ACE inhibitors Potassium-sparing diuretics Beta blockers

Question 5
Classic signs and symptoms of deep vein thrombosis (DVT) include:

Positive Homans signBlanching of the extremity, followed by cyanosisSudden onset of unilateral swelling of one legIntermittent claudication

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Answer: DRationale: An estimated 81 million U.S. adults have one or more types of CVD.
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Answer: BRationale: A patient with atherosclerosis and diabetes should have a LDL-C level less than 70 mg/dL. Elevated LDL-C levels increase the risk for cardiovascular problems. A desirable HDL-C level is 40 mg/dL or above. Total serum cholesterol levels should be below 200 mg/dL, and triglyceride levels should be below 150 mg/dL.
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Answer: BRationale: In 2003, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure made significant changes in classifying blood pressure in adults. The new classification for normal adult blood pressure is less than 120 mm Hg systolic and less than 80 mm Hg diastolic. Adults with a blood pressure (BP) of 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic, considered normal under previous guidelines, are now classified as prehypertensive and are in need of lifestyle changes to prevent cardiovascular complications.
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Answer: DRationale: Even though thiazide diuretics are often considered the first-line drug treatment for hypertension, beta blockers are the drug of choice for hypertensive patients with ischemic heart disease (IHD) because the heart is the most common target of end-organ damage with hypertension.
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Answer: CRationale: People with DVT may have symptoms or may be asymptomatic. The classic signs and symptoms of DVT are calf or groin tenderness and pain and sudden onset of unilateral swelling of the leg. Pain in the calf on dorsiflexion of the foot (positive Homans sign) appears in only a small percentage of patients with DVT, and false-positive findings are common. Therefore checking a Homans sign is not advised!