Vascular Problems

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Vascular Problems
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Arteriosclerosis

• Thickening, or hardening of the arterial wall

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Atherlosclerosis

• A type of arteriosclerosis
• Involves the formation of plaque within arterial
  wall
• Most common cause of arterial obstruction
• Rate of progression determined by
• Genetic factors
• Chronic diseases (diabetes mellitus)
• Lifestyle habits (smoking)
• Dietary habits (fatty foods)
• Level of exercise

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Atherlosclerosis

• Assessment
• Hypertension (evaluate BP in both arms)
• Cool/cold extremities
• Diminished or absent peripheral pulses
• Prolonged capillary refill (gt 3 sec gt 5 sec)
• Bruits ascultated in large arteries
• Decreased intensity and audibility, or loss of
  pulse may indicate an arterial obstruction

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Atherlosclerosis

• Laboratory Assessment
• Total serum cholesterol level (lt200mg/dL)
• Elevated cholesterol levels must be validated by
  HDL and LDL determination
• Desirable LDL lt 100 mg/dL
• Desirable HDL 35 mg/dL or above
• Triglycerides (lt 200 mg/dL)
• Homocysteine

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Homocysteine

• Essential sulfur containing amino acid derived
  from protein
• Increased homocysteine levels associated with
  greater risk for
• Peripheral Vascular Disease
• Coronary Artery Disease
• Level gt 15 considered a risk factor
• Folic acid (1mg/day) can lower homocysteine levels

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Atherlosclerosis

• Interventions
• An insidious disease
• Cholesterol screening can identify persons at
  risk
• Managed with diet, smoking cessation, exercise,
  and drug therapy

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Diet Therapy

• Goal lowering low density lipoprotein (LDL)
• Modified-fat diet
• Step One diet total fat intake of less than 30
  of total calories, with 10 of total calories
  coming from saturated fat and 10-15 coming from
  polyunsaturated fat. Cholesterol intake limited
  to less than 300 mg daily.
• Step Two diet further restricts saturated fat to
  7 of total calories and Cholesterol to 200 mg
  daily

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Smoking Cessation

• Cigarette smoking lower levels of HDL and
  dramatically increases the rate of progression of
  Atherosclerosis
• Advise against not smoking and avoiding second
  hand smoke
• Nicotine patches or gum can be used to relieve
  nicotine withdrawal symptoms
• Caution not to smoke while nicotine patch in place

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Exercise

• Promotes optimal lipid levels
• Can prevent atherosclerosis
• Can lead to regression of plaque and development
  of collateral circulation
• Recommend 30 minutes moderate to vigorous
  exercise 3-4 times per week

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Drug Therapy

• Added to when diet and exercise do not lower
  lipid levels
• Drug choice is dependent upon triglyceride level
• Bile acid binding resins (Questran) may be use
  initially because of low toxicity
• Statins (Mevacor, Zocor) lower LDL and
  triglyicerides
• Nicotinic acid lowers LDL and increases HDL
• Fibric acid derivatives raise HDL and lowers
  triglycerides and VLDL
• (Chart 36-1, p. 733)

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Hypertension

• Systolic blood pressure gt 140mm Hg and/or
  diastolic blood pressure gt 90mm Hg
• Determined by two separate readings
• Classified into 3 stages (Table 36-3, p. 733)
• Major risk factor for development of chronic
  diseases (coronary, cerebral, renal and
  peripheral vascular)

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Regulation of Blood Pressure

• Arterial baroreceptors
• Regulation of body fluid volume
• Renin-Angiotensin-Aldosterone System
• Vascular Autoregulation

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Complications of Hypertension

• Myocardial infarction
• Cerebral vascular accident
• Peripheral vascular disease
• Renal failure

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Malignant Hypertension

• Severe elevated blood pressure
• Rapidly progressive
• Symptoms
• Morning headaches
• Blurred vision
• Dyspnea/uremia
• Systolic BP gt 200mm Hg, Diastolic BP gt 150 mm Hg
  (or gt 130mm Hg if other conditions present)
• Untreated can result in renal failure, left
  ventricular failure, or stroke

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Essential Hypertension

• No known cause (accounts for 90 of cases)
• Associated risk factors
• Age (gt 60, family hx)
• Excessive calorie consumption, inactivity
• Excessive alcohol intake
• Hyperlipidemia
• African-American ethnicity
• High salt/caffeine intake
• Reduced potassium/calcium/magnesium intake
• Obesity, smoking, stress

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Secondary Hypertension

• Related to specific disease states and
  medications
• Diseases
• Renal vascular/renal parenchymal
• Dysfunction of adrenal medula or cortex
• Coarctation of the Aorta
• Brain tumors, encephalitis, psychiatric disorders
• Medications
• Estrogen
• Glucocorticoids
• Mineralocorticoids
• Sympathomimetics, cyclosporin, erythropoietin

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Secondary Hypertension

• Clinical manifestations
• Asymptomatic
• Headaches, dizziness, fatigue
• Vascular changes in the retina
• Abdominal bruits
• Tachycardia
• Sweating/pallor
• Delayed/absent femoral pulses

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Hypertension Nursing Dx

• Deficient Knowledge
• Risk for Ineffective Therapeutic Regimen
  Management
• Ineffective Tissue Perfusion
• Goal
• BP maintained within normal limits
• No evidence of target organ damage

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Hypertension

• Interventions
• Sodium restriction
• Weight reduction
• Moderation of alcohol intake
• Exercise
• Relaxation techniques
• Avoidance of tobacco
• Drug therapy

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Hypertension

• Drug Therapy
• Diuretics
• Beta-adrenergic blocking agents
• Calcium channel blockers
• ACE inhibitors
• Angiotensin II receptor antagonists
• Central alpha agonists
• Vasodilators
• Alpha-adrenergic receptor agonists

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Peripheral Vascular Disease

• Includes disorders that alter the natural flow of
  blood thorough the arteries and veins of the
  peripheral circulation. Lower extremities
  affected more often than upper.
• Peripheral Arterial Disease (PAD)
• Most common
• Peripheral Venous Disease

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Peripheral Arterial Disease

• Chronic with partial to total arterial occlusion
• Deprives lower extremities of oxygen and
  nutrients
• Atherosclerosis is most common cause
• Classified as
• Inflow involve distal end of aorta and the
  common, internal and external iliac arteries
• Outflow involve infrainguinal arterial segments
  and are below the superficial femoral artery
• Risk factors same as for atherosclerosis

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Peripheral Arterial Disease

• Assessment
• Pain
• Intermittent claudication
• Rest pain
• Discomfort lower back, buttocks, thighs
• Burning or cramping in the calves, ankles, feet,
  and toes

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Peripheral Arterial Disease

• Clinical Manifestations
• Loss of hair lower calf, ankle, foot
• Dry, scaly, dusky, pale or mottled skin
• Thickened toenails
• Cold, cyanotic or darkened extremity
• Pallor when extremity ?, rubor when ?
• Diminished/absent peripheral pulses
• Arterial/Venous stasis ulcers
• Diabetic ulcers

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Peripheral Arterial Disease

• Diagnostic Assessment
• Arteriography of lower extremities
• Segmental systolic blood pressure measurements
• Exercise tolerance testing
• Plethsmography

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Peripheral Arterial Disease

• Interventions
• Non-surgical
• Exercise
• Positioning
• Promoting vasodilation
• Drug therapy
• Percutaneous transluminal angioplasty
• Laser-assisted angioplasty
• Atherectomy

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Peripheral Arterial Disease

• Surgical Management
• Arterial revascularization
• Inflow procedures
• Aortoiliac bypass
• Aortofemoral bypass
• Axillofemoral bypass
• Outflow procedures
• Femoropopliteal bypass
• Femorotibial bypass

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Peripheral Arterial Disease

• Post-op care
• Assessment for graft occlusion
• Promotion of graft patency
• Treatment of graft occlusions
• Monitoring for compartment syndrome
• Assessment for infection

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Acute Peripheral Arterial Occlusion

• Onset is sudden and dramatic
• Embolus is most common cause
• Most originate from heart post MI or afib
• Most common in lower extremities
• Assessment Six Ps of ischemia
• Pain, pallor, pulselessness
• Paresthesia, paralysis, poikilothermia

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Acute Peripheral Arterial Occlusion

• Interventions
• Anticoagulant therapy
• IV Heparin
• Surgical thrombectomy/embolectomy
• Patch graft

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Aneurysms

• Permanent localized dilation of an artery
• Types
• Fusiform/saccular
• True/false
• Dissecting hematomas (aneurysms)
• Abdominal aoritc aneurysms (AAA)
• Thoracic aortic
• Etiology
• Atherosclerosis
• Hypertension
• Cigarette smoking

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Abdominal Aortic Aneurysm

• Often asymptomatic
• Common sites of pain
• Abdomen, flank, back
• Detectable signs
• Pulsation slightly to L of midline between
  xiphoid process and umbilicus
• Bruit over mass
• Signs of impending rupture
• Sudden onset of severe pain in back or lower
  abdomen radiating to groin, buttocks, or legs

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Abdominal Aoritc Aneurysm

• Ruptured or Rupturing Aneurysm
• Medical Emergency
• Hypovolemic shock
• Hypotension
• Diaphoresis
• Mental obtundation
• Oliguria
• dysrhythmias
• Retroperitoneal hemorrhage hematomas in flank
• Abdominal hemorrhage distention

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Abdominal Aortic Aneurysm

• Radiographic Assessment
• Abdominal xray or lateral film of the spine will
  often identify aneurysm
• CT scan is standard tool

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Abdominal Aortic Aneurysm

• Interventions
• Non-surgical
• Monitor growth of aneurysm and maintain blood
  pressure at normal level to ? risk of rupture
• Surgical
• May be elective (aneurysm gt 6 cm) or emergency

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Peripheral Venous Disease

• Alteration of blood flow in veins
• Thrombus formation (venous thrombosis)
• Defective valves
• Blood clot develops, Virchows triad injured
  endotherlium, venous stasis, hypercoagulability
• Associated with an inflammatory process
• Thrombophlebitis
• Deep venous thrombophlebitis (DVT)

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Peripheral Venous Disease

• Assessment
• May be asymptomatic
• Classic s/s DVT calf or groin tenderness or
  pain
• Sudden onset of unilateral swelling

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Peripheral Venous Disease

• Interventions
• Non-surgical management
• Rest
• Elevation of extremity
• Moist soaks
• Monitor for s/s of pulmonary embolus
• Compression stockings
• Drug therapy
• Heparin
• Coumadin
• Thrombolytic therapy

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Peripheral Vascular Disease Drug Therapy

• Heparin
• Baseline PT, aPTT, INR, CBC, platelet, U/A, and
  creatinine
• Bolus dose followed with continuous infusion
• Dosage regulated by aPTT (therapeutic range 1-2 X
  normal control levels)
• Protamine sulfate is antidote
• Can ? platelet counts, severe reductions can lead
  to white clot formation which can cause
  thrombosis

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Peripheral Vascular Disease Drug Therapy

• Low-Molecular Weight Heparin
• Action is consistent
• Longer half-life and more predictable response
• Approved for prevention and treatment of DVT

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Peripheral Vascular Disease Drug Therapy

• Warfarin (Coumadin)
• Works in liver to inhibit synthesis of vitamin K
  dependent clotting factors
• Takes 3-4 days to reach therapeutic levels
• Regulated by PT and/or INR
• INR should be between 2.0 and 3.0
• Long term therapy (3-6 months post DVT or longer)
• Vitamin K is antidote

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Peripheral Vascular Disease Drug Therapy

• Thrombolytic therapy
• Systemic thrombolytics can sucessfully dissolve
  clots
• Can prevent valvular damage and consequential
  venous insufficiency
• Contraindicated post-op, post trauma,
  post-partum, post cva or spinal injuries
• Streptokinase, t-PA, ReoPro
• Must observe closely for signs of bleeding

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Peripheral Venous Disease

• Surgical management
• Thrombectomy
• Inferiour vena caval interruption
• Ligation or external clips