Vascular Disease

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Vascular Disease

• Terri Slifer Lynch, MSN, RN, BC

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Aortic Aneurysm

• A sac or dilation formed at a weak point
• One or all three layers may be involved
• May rupture and lead to death

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Characteristics of Aneurysms

• False aneurysm blood escapes into connective
  tissue, outside of arterial wall

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• Fusiform aneurysm- symmetric, spindle-shaped
  expansion. Involves entire circumference

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• Saccular aneurysm out-pouching on one side only

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• Dissecting aneurysm separation of arterial wall
  layers that fills with blood

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Thoracic Aortic Aneurysm

• Occurs most frequently in men, 50 70 yrs of age
• Etiology atherosclerosis, hypertension,
  infection
• 1/3 die from rupture

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Assessment Findings with Thoracic Aneurysm

• May be asymptomatic
• Chest pain
• Dyspnea, hoarseness or dysphagia
• Distended neck veins and edema of head and arms

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Diagnostic Studies

• Chest xray
• Transesophageal echocardiogram
• CT scan

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Medical Management of Thoracic Aneurysm

• Control underlying hypertension
• Surgical repair
• Resection of aneurysm and replacement with graft
• Repair with endovascular graft

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Nursing Interventions

• Similar to those with coronary artery bypass
  grafting or post cardiac cath

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Abdominal Aortic Aneurysm(AAA)

• Occurs more frequently in caucasians, more in men
  and elderly clients
• Etiology atherosclerosis, hypertension, trauma,
  infection, congenital abnormalities in vessels,
  genetic predisposition
• Most are infrarenal

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Assessment Findings with AAA

• Approximately 60 of clients are asymptomatic
• Pulsatile mass in the upper and middle abdomen
• Abdominal or low back pain
• Bruit may be heard
• Diminished femoral and distal pulses
• Patchy mottling of feet and toes

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Diagnostic Tests with AAA

• Abdominal ultrasound
• CT scan, MRI

The aortic abdominal aneurysm has an intramural
thrombus, and its size is approximately 6.7 cm in
diameter. The true lumen of the aorta is
indicated by the arrowheads.
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Medical Management of AAA

• If small, monitor every 6 months
• Keep BP down
• Surgery is treatment of choice if greater than
  5cm or enlarging
• Surgical resection and replacement with a graft
• Repair with endovascular graft

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Nursing Interventions for Client with AAA

• Pre-operatively close monitoring for dissection
  or rupture of AAA and prepare for surgery
• Signs of dissection - severe back or abdominal
  pain, elevated BP, decreased pedal pulses
• Signs of rupture constant, intense back pain
  falling BP, shock, death

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• Post-operatively
• Hemodynamic monitoring
• Frequent VS checks
• Neuro checks
• Assess heart and lungs

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• Encourage turning, coughing and deep breathing
• Assess for and prevent thrombophlebitis
• Assess for paralytic ileus
• Assess renal function
• Maintain patient flat in bed without sharp
  flexion of hips/knees

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• Discharge teaching
• Avoid heavy lifting/straining for 4-6 weeks
• Gradually increase activities
• Avoid prolonged sitting or standing and smoking
• Observe for changes in color and temperature of
  extremities check pedal pulses
• Prophylactic antibiotics before invasive
  procedures

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Peripheral Vascular Disease (PVD) Encompasses
Three Systems

• Arterial
• Venous
• Lymphatic

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Arterial Insufficiency or Peripheral Arterial
Occlusive Disorders

• Involves narrowing of arterial lumens or damage
  to the lining
• Blood flow can be partially obstructed or
  completely occluded
• Chronic disease differs from acute
• Found more in men over 50 yrs
• Legs most frequently affected

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Risk Factors For Arterial Occlusive Disease

• HTN
• Hyperlipidemia
• Diabetes
• Nicotine use
• Inflammation
• Autoimmune disorders
• Obesity
• Trauma

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Clinical Manifestations of Chronic Arterial
Insufficiency/Occlusion

• Intermittent claudication hallmark
• Pain at rest develops as disease progresses
• Extremity cool to touch
• Weak or absent peripheral pulses
• Rubor and cyanosis when extremity is dependent
  and pallor with elevation

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• Hypertrophied nails, skin dry with sparse hair
• Sensation of numbness or tingling
• Skin ulcerations and gangrene of digits
• Bruits over stenosed vessels

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Diagnostic Findings With Arterial Occlusive
Disease

• Decreased Ankle-Brachial Index (ABI) 0.50 to
  0.95 indicates mild to moderate insufficiency.
  0.25 or less severe
• Ankle pressure ABI (normally 1.0)
• Brachial pressure

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• Duplex ultrasound
• Exercise testing
• Arteriogram angiography

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Medical Management of Chronic Arterial Occlusive
Disease

• Smoking cessation
• Exercise program
• Weight reduction
• Meds to promote arterial blood flow
• Trental (pentoxifylline)
• Pletal (cilostazol)

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• Protect from injury
• Avoid constrictive clothing and crossing legs
• Reduce lipids
• Supplemental carnitine

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Surgical Management of Arterial Occlusive Disease

• CLiRPath
• Endarterectomy
• Bypass grafting
• Angioplasty and stent
• Amputation

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Post-operative Nursing Management Post Bypass
Grafting

• Check pulses of affected extremity frequently
• Monitor pain, color, sensation, motor function,
  capillary refill frequently
• Monitor for swelling
• Monitor VS and IO
• Leg crossing and prolonged dependency of
  extremity is to be avoided
• Keep leg extended

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Etiology of Acute Arterial Occlusion

• Trauma
• Embolus
• Thrombosis

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Clinical Manifestations Of Acute Arterial
Occlusion (6Ps)

• Pain
• Pulselessness
• Pallor
• Paresthesia
• Poikilothermia
• Paralysis

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Diagnostic Studies For Acute Arterial Occlusion

• Duplex ultrasonography
• Arteriography
• ECHO

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Medical Management Of Acute Arterial Occlusion

• Heparin drip
• Embolectomy
• Thrombolytic agents
• Amputation

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Raynauds Disease

• Small arteries and arterioles of hands and feet
  constrict or vasospasm
• Cause unknown
• More frequent in women ages 16-40 yrs
• Induced by cold, stress, caffeine, nicotine
• Manifestations coldness, pain or numbness,
  pallor, cyanosis of fingers and toes which
  progress to rubor (white, blue, red)

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• Dx noninvasive blood flow studies before and
  after cold application
• Medical tx
• Calcium channel blockers Norvasc (amlodipine),
  Procardia (nifedipine)
• Alpha adrenergic receptor blockers prazosin
  (Minipress), doxazosin (Cardura)
• Nitrates transdermal or long acting oral
  nitrates
• Avoid smoking, cold, stress and ETOH, limit
  caffeine and chocolate

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• Nursing management
• Teach client relaxation techniques, biofeedback
• Teach client to minimize exposure to stimuli
• Teach client to wiggle and massage digits
• May apply warmth to extremities intermittently

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Thromboangiitis Obliterans (Buergers Disease)

• Inflammation or vasculitis of small and medium
  sized arteries and veins in the extremities
• Thrombus formation occurs and occludes vessels
• Cause is unknown

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• Clinical manifestations
• Claudication with exercise in arches of feet
• Digital pain which may be constant
• Intense rubor or cyanosis of feet when dependent
• Absent or decreased pedal or radial pulses
• Ulcerations and gangrene commonly occur

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• Dx Duplex ultrasound, arteriogram and biopsy of
  vessels
• Tx
• Improve circulation
• Relieve pain
• Protect from injury and infection
• Amputation if gangrene

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Nursing Care After Amputation

• Monitor stump for bleeding, hematoma
• Avoid elevation of stump after 24 hrs
• Prevent hip and knee contractures
• Encourage client to verbalize feelings
• Assess clients ability to manage independently
  after discharge
• Assist client in plan to stop smoking

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Expected Outcomes For the Client With Arterial
Vascular Disease

• Demonstrates an increase in arterial blood flow
  to extremities
• Decrease in severity and duration of pain
• Maintains or achieves intact skin integrity
• Promotes vasodilation and prevents vascular
  compression
• Absence of complications

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Varicose Veins(Varicosities)

• Abnormally dilated tortuous veins
• May be superficial or deep
• Commonly affects veins in lower trunk
• Most common in women and people who stand for
  long periods
• Genetic component
• Can progress to chronic venous insufficiency

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Clinical Manifestations of Varicose Veins

• Swollen, dilated, tortuous veins
• Dull aching
• Muscle cramps
• Increased muscle fatigue
• Ankle edema
• Diagnosis duplex ultrasound

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Nursing Interventions To Prevent Varicosities

• Avoid activities that cause venous stasis
• Elevate legs frequently
• Encourage walking
• Apply elastic compression stockings
• Encourage weight loss

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Medical Management

• Ligation of veins
• Sclerotherapy
• Laser therapy
• Radiofrequency ablation

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Nursing Management After Vein Ligation

• Routine post-op
• Ambulate ASAP per orders
• Foot of bed elevated
• Elastic compression dressings or stockings

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• Monitor for sensations of pins needles
• Avoid application of lotion
• Administer mild analgesics as ordered
• Instruct client to avoid standing or sitting for
  long periods of time

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Other Venous Disorders

• Venous thrombosis thrombus formation in a vein.
  May be deep (DVT) or superficial
• Thrombophlebitis inflammation of a vein along
  with thrombus formation

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Virchows Triad

• Venous stasis due to reduced blood flow
• Injury to the intimal lining creates site for
  clot formation
• Hypercoagulability increased tendency to clot

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Complications Of Venous Thrombosis

• Pulmonary embolus
• Chronic venous insufficiency
• Venous stasis ulcers
• Chronic edema

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Clinical Manifestations of Superficial Venous
Thrombosis

• Pain
• Tenderness
• Redness
• Warmth
• Palpable cord

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Clinical Manifestations Of DVT

• Swelling or edema of involved extremity
• Tenderness
• Homans sign
• Signs of pulmonary embolus
• Chest pain
• Hemoptysis
• Dyspnea
• Apprehension
• Hypotension
• Cardiac arrest

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Diagnosis of Venous Thrombosis

• Venous duplex scanning
• D-dimer test
• Venogram

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Preventative Measures For Venous Thrombosis and
Thrombophlebitis

• Active or passive leg exercises
• Intermittent pneumatic compression devices
• Compression stockings
• Encourage post-op deep breathing
• Avoid using pillows under knees

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• Elevate foot of bed
• Encourage walking ASAP post-op
• Do not cross legs
• Pharmacologic prevention to reduce
  hypercoagulability
• Adequate hydration
• Stop smoking

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Medical Management Of Superficial Thrombophlebitis

• Elevation of extremity
• Warm compresses to area
• Analgesics and possibly NSAIDS
• Possibly antibiotics

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Medical Management Of DVT

• Bedrest with extremity elevated
• Anticoagulation
• Heparin (unfractionated)
• Given IV for 5-7 days
• Prevents conversion of prothrombin to thrombin
  and fibrinogen to fibrin
• Half-life approximately 2 hrs
• Monitor partial thromboplastin time (PTT) or anti
  Xa assay
• Protamine sulfate is antidote
• Must monitor platelets for Heparin Induced
  Thrombocytopenia (HIT)

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• Low molecular weight (LMW) heparin Lovenox,
  Fragmin
• Given only SQ, daily or BID
• Dose is weight based
• Do not expel air bubble
• Lower risk of HIT and bleeding
• No need to monitor PTT

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• Acova (argatroban) and Refludan (lepirudin)
• Direct thrombin inhibitors
• Given continuously IV to patients allergic to
  Heparin or who experience HIT
• No know antidote
• Monitor PTT

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• Arixtra (fondaparinux)
• Inhibits factor Xa
• Given SQ at a fixed dose, once daily
• Excreted by kidneys
• Do not expel air bubble in syringe
• No known antidote

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• Coumadin (warfarin)
• Given long term
• Inhibits hepatic synthesis of Vit K
• Half-life is 0.5-3 days
• Vit K is antidote
• Monitor Prothrombin time
• PT 1.5 - 2.5 times control
• International Normalized Ratio (INR) - 2.0-3.0

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• Thrombolytic therapy
• Lyse and dissolve clot
• Results in a 3 fold greater incidence of bleeding
  than Heparin
• Drugs Urokinase, Streptokinase, t-PA, Activase
• Plication of inferior vena cava
• Filter inserted into vena cava to trap emboli

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Nursing Management Of Client With DVT

• Administer and monitor anticoagulant therapy
• Administer continuous IV Heparin via pump
• Administer LMW heparin SQ only do not expel
  air, aspirate, or massage site, and avoid scars
  and umbilicus
• Monitor PTT or anti Xa assay
• Monitor PT
• No IM medications or meds with ASA

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• Monitor and manage complications
• Bleeding expistaxis, hematuria, melena,
  bleeding gums, hematoma formation
• Thrombocytopenia platelets less than 100,000 or
  25 decrease from previous level, increasing
  Heparin doses required
• Pulmonary embolus

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• Provide bed rest with involved extremity elevated
  or FOB elevated
• Apply warm moist heat to affected extremity per
  order
• Measure thighs, calves and ankles daily
• Relieve discomfort

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• Provide client teaching and discharge planning
• Teach client measures to prevent recurrence
• Encourage rest periods with feet elevated
• Use of elastic stockings when ambulating

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• Teach client regarding Coumadin therapy
• Stress importance of follow-up for PT
• Do not take OTC meds, vitamins, herbs
• Avoid alcohol
• Avoid large amounts of foods with Vit K
• Signs and symptoms to notify physician of
• Wear Medic Alert bracelet

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Chronic Venous Insufficiency

• Results from faulty venous valves which allow
  reflux of blood
• Venous pressure increases and venous stasis
  occurs. Edema also occurs.
• Small veins rupture and RBCs escape into
  surrounding tissues.
• Brown discoloration of tissues occurs
• Stasis ulcers develop

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Clinical Manifestations Of Chronic Venous
Insufficiency

• Swollen limb
• Dry, itchy, coarse, leathery skin
• Reddish brown skin on lower extremity above
  ankles
• Stasis ulcers above ankles

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Diagnosis

• Duplex ultrasound

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Medical and Nursing Management of Chronic Venous
Insufficiency

• Elevate legs frequently throughout the day
• Sleep with FOB elevated approximately 6 in
• Walking is encouraged avoid prolonged sitting or
  standing

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• Avoid pressure on popliteal space
• Elastic pressure stockings reduce venous stasis
• Protect from trauma
• Report ulcerations immediately

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Leg Ulcers

• 75 result from chronic venous insufficiency and
  20 from PAD
• Appear as an open, inflamed sore.
• Eschar may be present.
• Venous ulcers usually present above the malleolus
• Arterial ulcers usually occur on or between toes

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Treatment of Stasis Ulcer(Venous or Arterial)

• Wound culture
• Oral antibiotics if infection present
• Debridement of nonviable tissue
• Surgical debridement
• Enzymatic debridement
• Wet to dry dressings
• Calcium algenate dressings

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• Keep ulcer clean and moist while healing
• Hydrocolloid dressing
• Unna boot
• Improve nutrition
• Hyperbaric oxygen therapy (HBO)

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Expected Outcomes For Client With Venous Disorders

• Maintains or achieves intact skin integrity
• Decrease in pain
• Absence of complications
• Adheres to self-care program

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Disorders Of Lymphatic System

• Lymphangitis
• Acute inflammation of lymphatic channels
• Most commonly caused by bacterial infection
• Characteristic red streaks outline lymphatic
  vessels
• Tx - antibiotics

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• Lymphandenitis
• Enlarged, tender, inflamed lymph nodes
• Usually nodes of groin, axilla or cervical region
  affected
• Caused by infection
• Tx with antibiotics if bacterial

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• Lymphedema
• Swelling of tissues in an extremity
• Results from an obstruction of lymphatic vessels,
  hypoplasia of lymphatic system, parasites,
  interruption of system
• Tx reduce and control edema and prevent
  infection

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• Control edema
• Elevate extremity
• Active and passive exercises
• Massage
• External compression garments
• No BP checks or IV in affected extremity

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