Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation

Health History: arterial

-Pain

-Intermittent Claudication: pain (muscular, crampy), discomfort or fatigue cause by inability to the arterial system to provide adequate blood flow to the tissues in the face of increased demand s for nutrients and oxygen during exersice

-Pain occurs as metabolites aggravate the nerve endings in surrounding tissue

-50-70% of lumen obstructed before pain occurs

arterial issue

-getting blood from heart to periphery

-no oxygen getting to extremities

-ex: intermittent claudication/fatigue

physical assessment PAD

◦Inspection of skin (pallor, rubor with dependent position)

◦Loss of hair

◦Brittle nails

◦Dry, scaling skin

◦Atrophy

◦Ulcerations- dry and occur in the periphery

◦Edema

◦Gangrenous changes (dry)

-Pulses

Diagnostic Evaluation for PAD

-Doppler Ultrasound Studies

-Ankle-brachial index (ABI)-> ratio of systolic blood pressure in the ankle to the systolic blood pressure in the arm

◦Able to quantify the degree of stenosis

◦With increasing disease there is a progressive decrease in Systolic pressure distal to involved sites

-Exercise testing

-Duplex Ultrasonography

-CT scanning

-Angiography

exercise testing

see how long patient can walk without caludication, ankle BP will drop and AKI will be large

Duplex Ultrasonography

non invasive

CT scan

-contrast injected

-watch allergies and renal function (order baseline BUN and Creatanine)

angiography

isolate blood vessels to look at them

arterial pain pulses and skin

Pain

-Intermittent claudication to sharp unrelenting (calf)

Pulses

diminished or absent

-may hear bruit

-pulses can be unequal

Skin

-dependent–rubor

-elevation-pallor

-shiny

-cool to cold

-nails thickened and rigid

-less hair

venous pain, pulses, and skin

Pain

-aching, cramping

Pulses

-Present but may be difficult to palpate through edema

Skin

-pigmentation-medial and lateral malleolus

-thickened

-tough skin

-frequently reddish –blue color & associated with dermatitis

venous issues mean

blood pools

arterial ulcer

-location

-pain

-shape

-base

-leg edema

Location: tips of toes, toe webs, heel starts in periphery and moves up

Pain: very painful

Depth: deep often into joint

Shape: circular

Base :Pale to black and dry gangrene

Leg Edema: minimal unless leg is in a dependent position

venous ulcer

-location

-pain

-shape

-base

-leg edema

Location:

-medial or lateral malleolus (ankle)

-anterior tibial area

Pain: minimal if superficial (because they have circulation)

Depth : superficial

Shape: irregular border

Base: granulation tissue, beefy red to yellow fibrinous if chronic

Leg Edema: moderate to severe

Diagnostic tests for PVD

-venography

-along with all the PAD tests

Prevention

-Reduction of fat in diet

-Exercise

Reduce lipid levels (LDL < 100)

-Cholesterol < 200

-Triglyceride < 150

Statins

◦Lipitor, Mevacor, Zocor, Pravachol, Crestor

-Niacin, Questran, Zetia

-Manage HTN

medical management

-surgical

-radiologic procedures

surgical management

Vascular surgical procedures

◦Improve blood supply from aorta to femoral artery

◦Outflow procedures: provide blood supply to vessels below the femoral artery

radiologic procedures

◦Arteriogram

◦Angiography (both)

-venogrpahy

patient on statins what do you monitor

liver enzymes/function

Nursing Management

-Improving Peripheral Arterial Circulation (exercise and dangle legs)

-Promoting Vasodilation and Preventing Vascular Compression (warm compress becareful because they can burn easily)

-Relieve Pain

-Maintain Tissue Integrity

what does walking help improve

collateral circulation

-walk walk walk until pain, then rest, then walk again.

a patient with PAD when they elevate legs what will happen

the legs will be pale

neurovascular check is what

6 Ps

medical management of PAD

-Exercise program

-Walking program

-Cessation of tobacco use

-Endarterectomy

-Bypass grafts

PAD Pharmacological Therapy

SYMPTOMATIC CLAUDICATION

-Trental- decreases viscosity to help blood flow better

-Pletal- vasodilator and inhibits platlet agregation

ANTI-PLATLET

-Aspirin (ASA)

-Plavix

Stabalize plaque

-Statins

nursing management to maintain circulation PAD

◦frequent checks for pulses, color, capillary refill, temp

-check area distal to the graft

-no pulse contact HCP

nursing management Potential complications PAD

◦urine output, mental status, central venous pressure and pulse rate

◦prevent thrombosis by no leg crossing and no prolonged leg dependence

Discharge planning PAD

◦assessment of patient's ability to be independent

◦educate the patient regarding lifestyle modifications

Aneurysms

Localized sac or dilation formed at a weak point in the wall of an artery

Life threatening-> rupture leads to hemorrhage and death

saccular vs fusiform vs dissecting

◦Saccular- ON ONE WALL

◦Fusiform -all the way around

-dissecting-ruptured all blood comes rushing out

Thoracic Aortic Aneurysm

-70% of all cases cause by atherosclerosis

-50-70 years

-Most common site for dissecting aneurysm

-1/3 of patient with thoracic aneurysm die due to rupture

-chest xray

Clinical Manifestations of thoracic aneurysms

-Variable, dependent on how rapidly the aneurysm dilates and how the pulsating mass affects surrounding intrathoracic structures

-Asymptomatic

Constant, boring (may occur only when supine)

-Dyspnea or cough

-Hoarseness, stridor or aphonia

-Large veins in chest compressed: become dilated

Diagnosis for thoracic aortic anyeurism

-Chest x-ray

-Computed tomography angiography (CTA)

-Transesophageal echocardiography (TEE)

medical management for Thoracic anyeurysm pt one

Blood pressure control with dissection

◦SBP < 90-120 mm Hg or MAP < 60-75 mm Hg

◦Esmolol

◦Hydralazine

◦Nipride

medical management for Thoracic anyeurysm pt 2

Emergent surgery to repair aneurysm and restore vascular continuity with graft

◦3-4% risk of paraplegia

◦Endovascular grafts place percutaneously in interventional radiology

◦No cross-clamping required

graft pic

Abdominal Aortic Aneurysm

-Etiology->atherosclerosis

-Men> women

-Caucasian> black

-Location: Occur below the renal arteries (infrarenal aneurysm)

If untreated->eventual rupture and death

-Pathophysiology

◦Damaged medial layer of the vessel

abdominal aortic anyeurism clinical manifestation

-40% have symptoms

-Feel their heart beating in their abdomen when lying down

-Abdominal pulsatile mass

-Thrombus may occlude vessel -> emboli-> cyanosis and mottling of toes

does a patient with a minor anyeurysm get surgery

usually not right away -Evaluation via CTA every 6-months

Pharmacologic Management of abdominal aortic anyeurism

-Close blood pressure monitoring

-Antihypertensive agents

Diuretics

Beta-blockers

ACE inhibitors

Angiotensin II receptor antagonists

Calcium channel blockers

Surgical Treatment AAA

-Surgery is treatment of choice for AAA >5.5 cm (2 inches)

-Open surgical repair by resection and bypass grafting

-Mortality rate 1-4% with surgery

-Endovascular grafting: local or regional anesthesia

Dissecting Aorta

-Tear develops in the intima or media

-Dissections commonly associated with poorly controlled HTN, blunt chest trauma, cocaine use

-Tear occurs most commonly in the region of the aortic arch

Highest mortality with

-ascending aortic dissection

-Aorta sends the blood to the rest of the body

Clinical Manifestations dissecting aortic arch anyeurism

-Onset is sudden

Severe, persistent pain (tearing or ripping)

-Pain is anterior chest or back and extends to shoulders, epigastric area or abdomen

-Mistaken for an acute myocardial infarction

-Pale, diaphoretic

Tachycardia

-Blood pressure elevated and/or markedly different from one arm to the other

Arterial Embolism & Arterial Thrombosis

-happens from clot that develops in left side of the heart and goes to arterial circulation and get caught somewhere

-most common from Afib, AMI, endocarditis, HF

Arterial Embolism & Arterial Thrombosis CM

◦Depends on size, organ involvement and collateral circulation

◦Acute, severe pain

◦Gradual loss of sensory and motor function

◦Six P's: pain, pallor, pulseless, paresthesia, poikilothermic (cold), paralysis

Arterial Embolism & Arterial Thrombosis DIAGNOSIS

-CHEST XRAY

-ECG (tells us about underlying cardiac issues)

-TEE

Acute Thrombosis

occurs in patients with pre-existing ischemic symptoms

Manifestations acute thrombus

-similar to arterial emboli

-treatment is more difficult secondary to occlusion developing in a vessel which requires surgical reconstruction to restore blood flow

Assessment and Diagnostic Tests acute thrombosis

-Doppler Ultrasonography

Arteriography

◦determines the presence and extent of atherosclerosis

Nursing Management thrombus

-Bedrest with the affected extremity at bed level or slightly dependent

-Extremity is protected from mechanical trauma and kept at room temperature

-If thrombolytic medication administered->

◦ICU for close observation for possible hemorrhaging

-If surgery is indicated the appropriate consents are signed and after the patient is encouraged to move the extremity to prevent stasis of blood

-Possible Complications

◦metabolic abnormalities

◦renal failure

compartment syndrome

Raynaud's Phenomenon

-affects the small blood vessels

-usually in the extremities

-results in low blood flow

-occurs in cold temperatures

-Usually affects women between 16-40

-Varying degrees of involvement

PRIMARY Raynauds phenomenon

no underlying cause

secondary raynauds

◦In association with an underlying disease (rheumatoid arthritis, systemic lupus erythematosus, scleroderma, trauma or obstructive lesions)

raynauds classic clinical picture

bilateral and symmetrical, involves toes and fingers

-White/pallor secondary to sudden vasoconstriction->

-cyanotic secondary to pooling of unoxygenated blood during vasospasm-> exaggerated

-reperfusion results in rubor (red) secondary to oxygenated blood perfusing area

white, blue, red

management of raynauds

Avoid cold, tobacco and stress

what drug may relieve raynaud symptoms

-Calcium Channel Blockers may effectively relieve symptoms

-nitrates- vasodilation

Deep Vein Thrombosis

vein develop clot in the deep ones

Pulmonary Embolism

clot travels to lungs

-Affects approximately 10-20% medical patients & up to 80% critically ill

superficial and deep veins are effected

Superficial veins: greater saphenous, lesser saphenous, cephalic, basilic and external jugular veins

Deep veins: thin walled, less muscle

Virchow's Triad

decides who is at risk for DVT or PE

◦Endothelial damage

◦Venous stasis

◦Altered coagulation

Endothelial Damage

◦Trauma, surgery, pacing wires

◦Central venous catheters, dialysis catheters

◦Local vein damage, repetitive motion

Venous Stasis

◦Bed rest/immobilization

◦Obesity, age > 65

◦History of varicosities

◦Spinal cord injury

Altered Coagulation

◦Cancer

◦Pregnancy

◦Oral contraceptive use

◦Protein C & S deficiency

◦Polycythemia

◦Sepsis

ASSESSMENT findings for DVT

-Pain

-Heaviness

-Functional impairment

-Ankle engorgement

-Edema

-Increase temperature in leg

-Tenderness

-HOMANS SIGN IS NOT A RELIABLE SIGN FOR DVT

PREVENTION OF dvt

-lovonox

-ambulation

-SCD

-TED HOSE

-LEG EXCERICISES

-Patient with prior history of VTE are at increased risk of new episode: rate of recurrence is 25% in 5 years

DVP/PE: Medical Management

-prevent thrombus from growing and fragmenting (thus risking PE), recurrent thromboemboli and post thrombotic syndrome

-Superficial veins have a ____ of thrombi becoming DISLODGED

- EMBOLI

-lower chance

-dissolve spontaneously (treated at home with bed rest, elevation of leg, analgesics anti-inflammatory)

Anticoagulation Therapy

◦delays clotting time of blood

◦prevents the formation of a thrombus in postoperative patients

◦forestall the extension of a thrombus after it has formed

deep vein thrombosis needs to be put on

anti-coagulant therapy

-bed rest untill blood is therapeutic so clot wont dislondge

ANTICOAGULANT THERAPY CANNOT

◦cannot dissolve a thrombus that has already formed

Anticoagulation Therapy EXAMPLE

-Unfractionated heparin: Heparin

-Low-molecular weight heparin: Lovenox

-Oral anticoagulation: Coumadin

-Factor Xa Inhibitor: Arixtra

-Oral Factor XA inhibitor: Xarelto, Pradaxa

-Thrombolytic therapy: t-PA, TNKase

-Direct thrombin inhibitor: Refludan, Novastan

Contraindications to Anticoagulation

-Nonadherence to medications

Bleeding (GI, GU, Respiratory, Reproductive)

-Hemorrhagic blood dyscrasias

-Aneurysms

-Severer trauma

-Alcoholism

-Recent or impending surgery of th eye, spinal cord or brain

-Severe hepatic of renal disease

-Recent CVA

-Infections

-Open ulcerative wounds

-Occupation involving significant hazard

-Recent childbirth

Heparain (IV)/coumadin (po) monitor

APPT = draw blood from patient q4-6 hrs

-70-100 is therapeutic

-they titrate the drip to accomodate the therapeutic levels DRIP

-(1.5 TIMES NORMAL)

-if level is over 100 we stop the drip for an hour and restart it at a lower rate then it was at before (draw blood in 6 hrs), if less then 70 may need to increase

-For coumadin we do PT/INR qdaily

you keep them on heparin IV and coumadin PO untill when

coumadin has desired effects

-2-3

-once coumadin is at the level we want we stop heparin

Endovascular Management is Necessary when

anticoagulation or thrombolytic therapy is contraindicated, the danger of PE is extreme or venous drainage is severely compromised

-thrombectomy

-Ultrasound assisted thrombolysis

-vena cava filter

Assessing and monitoring anticoagulant therapy WHAT values are important

◦Heparin (aPTT 1.5 times normal)

◦Coumadin (INR 2.0-3.0)

vena cava filter

umbrella that opens to catch clots

-patients who cannot be on anti-coagulants

nursing management on anticoagulants

-Monitoring for bleeding, thrombocytopenia, drug interactions

-Providing comfort

-Compression therapy stockings

-Intermittent pneumatic compression devises

-External compression devices/wraps

Chronic Venous Insufficiency

-Results from obstruction of venous valves in legs or reflux of blood through valves

-Superficial and deep veins involved

-Venous HTN occurs

-PEOPLE WHO STAND FOR LONG HOURS AT RISK

which test confirms obstruction/identifies valvular incompetence?

Duplex ultrasonography

Chronic Venous Insufficiency: Management: Increasing venous blood flow

◦Antigravity activities-> elevate legs 15-20 minutes 4 times/day

◦At night-> foot of bed elevated 6 inches

◦Avoid prolonged sitting or standing

◦Encourage walking

◦Avoid crossing legs

-Graduated compression stockings

arterial ulcers

-Intermittent claudication

-Digital or forefoot pain at rest

-If acute-severe and unrelenting pain

-Small, circular, deep ulcerations of the tip of toes or the area between toes, and the medial side of the hallux or 5th lateral toe

-may never heal

venous ulcers

-Pain- aching or heavy

-Foot and ankle may be edematous

-Ulcers in medial or lateral malleolus, and usually large superficial and exudative

-Average of 6-12 months to heal and as many as 70% will reoccur within 5 years

Leg Ulcers: Management

Pharmacological therapy

◦antiseptic agents, systemic antibiotics

Compression therapy

◦Unna boots, graduated compression stockings

debridement promotes

healing

during necrosis to remove dead tissue

LEG ULCER MED MANAGEMENT (Hyperbaric Oxygen Chamber/ NEG pressure wound therapy)

Hyperbaric Oxygen Chamber

◦Can be used as an adjunct therapy especially in diabetic patients after no improvement in 30 days.

◦90 to 120 minutes once daily for 30 to 90 sessions

Negative pressure wound therapy using vacuum-assisted closure (VAC)

cellulitis is most common

Most common infectious cause of limb swelling

cellulitis manifestations

acute onset of swelling, localized redness, pain and can be accompanied by fever, chills, and sweating

management of cellulitis

Antibiotics (depending on the severity: outpatient or inpatient)

nursing management

elevate limb 3-6 inches above the heart every 2-4 hours and apply warm compresses