NRSG 250: Exam 2 - Vascular Disorders

What are the categories of coronary heart disease (CAD) outcomes?

1. chronic stable angina (CSA)

2. acute coronary syndrome (ACS)

   • unstable angina → approaching MI

   • MI

     • Non-ST segment MI (NSTEMI)

     • ST segment elevation MI (STEMI) = worse

What is arteriosclerosis?

hardening/thickening of arteries; often associated w/ aging

What is atherosclerosis?

type of arteriosclerosis involving plaque buildup in arteries

What is ischemia?

decreased O2 supply to myocardium

What is infarction?

irreversible cell death from prlonged ischemia

What are the risk factors of atherosclerosis?

Non-mod:

1. age

2. family hx

3. males or postmenopausal females

Modifiable:

1. smoking

2. HTN

3. DM

4. obesity

5. physical inactivity

6. high LDL

7. diet

What is the patho of atherosclerosis?

1. Endothelial injury

2. Lipid accumulation

3. Plaque formation

4. Coronary artery narrowing

5. Thrombus formation

6. Myocardial ischemia

→ MI (clot forms and gets stuck)

What is angina pectoris?

transient chest pain d/t myocardial ischemia (disruption in oxygen supply or increased demand)

• chronic stable angina

• acute coronary syndrome

What is the patho of angina pectoris?

1. anaerobic metabolism

2. tissue hypoxia

3. chest pain

What is chronic stable angina (CSA)?

predictable angina pectoris (chest discomfort, fullness, pressure, tightness) that occurs with moderate-to-prolonged exertion

What are the manifestations of CSA?

1. pain radiates to arm, neck, jaw, or back

2. slight limitation of activity

3. triggered by moderate ro prolonged exertion

4. similar pattern over several month

How is CSA managed?

1. rest

2. nitroglycerin

3. drug therapy

What is acute coronary syndrome?

type of angina where the atherosclerotic plaque in coronary artery ruptures → platelet aggregation, thrombus formation, and vasoconstriction

Types:

• unstable angina

• MI

What is unstable angina?

type of ACS where chest pain or discomfort occurs at rest or w/ exertion → severe activity limitation

• vasospastic angina

What are the manifestations of unstable angina?

1. occurs at rest or exertion → severe activity limitation

2. pain radiates to arm, neck, jaw, or back

3. last longer than 15 min

4. unrelieved by rest or nitroglycerin

5. ECG changes

What is vasospastic (variant / Prinzmetal) angina?

type of ACS caused by coronary artery spasm and typically occurs after rest

What are the manifestations of vasospastic angina?

1. occurs after rest

2. may cause transient ST elevation

How do you treat vasospastic angina?

nitrates and calcium channel blockers

What is myocardial infarction (MI)?

most serious ACS that occurs when myocardial tissue is abuptly and severely deprived of oxygen; can be caused by untreated angina

Types:

• NSTEMI

• STEMI

What are the manifestations of MI?

1. similar unstable angina S/S +

2. diaphoresis

3. weakness, dizziness, lightheadedness

4. N/V

5. SOB

6. anxiety & “impending doom”

What CAD manifestations may occur in women, older adults, and those w/ DM?

1. dyspnea

2. fatigue

3. nausea

all may occur w/o chest pain

What are the key points of NSTEMI?

1. ST depression, T-wave inversion → indicates myocardial ischemia

2. Initial normal troponin that elevates over next 3-12 hours → indicates myocardial cell death/necrosis

3. partial occlusion

4. urgent

Common causes:

• coronary vasospasm

• spontaneous coronary artery dissection

• sluggish blood flow d/t coronary artery narrowing

What are the key points of STEMI?

1. ST elevation

2. elevated troponin

3. complete occlusion

4. emergency

What is the initial assessment for the diagnostic evaluation of CAD & angina?

1. hx & symptom analysis

2. vital signs

3. 12-lead ECG

What is needed for the dx of MI besides ECG and troponin changes?

clinical symptoms (chest pain, SOB, nausea)

* pts w/ elevated troponin + ECG changes w/o clinical symptoms typically have condition other than CAD that causes imbalance btwn O2 supply & demand

What lab tests are used for the dx of CAD & angina?

1. Troponin I/T, CPK, myoglobin → detect myocardial injury

2. lipid profile → assess CAD risk

3. HbA1c → assess DM risk

What other noninvasive tests are used for the dx of CAD & angina?

1. stress test

2. ECG

3. nuclear perfusion imaging

4. CXR → r/o aortic dissection

What is the gold standard for dx CAD?

cardiac catheterization

What are the priority nursing diagnoses for angina pectoris?

1. acute pain r/t myocardial ischemia

2. ineffective tissue perfusion r/t decreased coronary blood flow

3. risk for decreased cardiac output r/t ischemia-induced dysrhythmias

4. risk for HF r/t ventricular dysfunction

What tx used to relieve ischemia in angina pectoris?

1. nitrates → rapid symptom relief

2. beta blockers → decreases myocardial oxygen demand

3. calcium channel blockers → alternative or adjunct therapy

4. supplemental O2

What tx is used to prevent CV events in angina pectoris?

1. aspirin (antiplatelet)

2. statins

What lifestyle moderations can reduce the risk of angina pectoris?

1. smoking cessation

2. BP control

3. DM management

4. physical activity as tolerated

What is used for revascularization in angina pectoris?

1. PCI (stent placement)

2. CABG

What should be known about nitroglycerin?

Nitroglycerin relieves angina but does not treat underlying atherosclerosis

What is peripheral arterial disease (PAD) and where is it most common?

atherosclerotic narrowing of peripheral arteries that reduces blood flow to the extremities

Common sites:

1. iliac arteries

2. femoral arteries

3. popliteal artiers

What is a complication of PAD?

LE ischemia and impaired tissue perfusion

What is the patho of PAD?

same atherosclerotic process as CAD

1. plaque narrows peripheral arteries

2. plaque deposits rupture & clots form

3. reduced arterial blood flow → tissue ischemia

What are the manifestations of PAD?

1. hallmark sign: intermittent claudication (angina of the legs)

2. rest pain

3. paresthesia

4. limb weakness

What are the assessment findings of PAD?

1. diminished/absent pulses

2. cool extremities

3. hair loss

4. thin, shiny skin

5. delayed cap refill

6 P’s

What could happens in advanced PAD?

1. poor wound healing

2. arterial ulcers

3. gangrene

What is intermittent claudication (IC) and its characteristics?

muscle pain/cramping w/ activity that is relieved by rest

1. most common symptom of PAD

2. predictable and reproducible

3. location depends on affected artery

4. may remain stable for years

What does IC indicate?

arterial insufficiency → worsening symptoms may signal progression to critical limb ischemia

What tx is used to prevent progression of PAD?

1. antiplatelets

2. statins

3. smoking cessation

4. control BP and DM

* PAD is not just about saving the leg → it’s about reducing CV risk and preventing MI and stroke

What tx is used to improve symptoms of PAD?

1. exercise

2. cilostazol (Pletal)

What tx is used to restore blood flow in PAD?

1. angioplasty/stenting

2. arterial bypass

What tx is used in advanced PAD?

1. wound care

2. limb salvage

3. amputation (last resort)

What tx is used to promote perfusion in PAD?

1. walking program

2. antiplatelet therapy

3. statins

4. smoking cessation

What positioning is used for PAD?

1. dependent positioning for ischemic pain

2. avoid prolonged leg elevation

What pt teaching is needed for PAD?

1. daily foot care

2. med adherence

3. risk factor modification

4. monitor for complication: 6 P’s of acute limb ischemia

What is acute arterial occlusion (acute limb ischemia) and what causes it?

occurs when a clot suddenly blocks an artery = limb-threatening emergency → requires immediate intervention

causes:

• embolism (most common)

• thromosis

• trauma

What are the manifestations of acute arterial occlusion?

7 P’s

1. pain → earliest symptoms

2. pallor → decreased perfusion

3. pulselessness → absent arterial flow

4. paresthesia → nerve ischemia

5. paralysis → threatened limb

6. poikilothermia (polar) → cold extremity

7. pistol shot → sudden onset

other:

• delayed cap refill and mottling (late)

What diagnostic tests are used for acute arterial occlusion?

1. doppler US

2. CT angiography

3. conventional angiography

What tx is used for acute arterial occlusion?

1. immediate anticoagulation → heparin

2. endovascular intervention

3. embolectomy/thrombectomy if indicated

What is an aneurysm?

permanent dilation of an artery caused by vessel wall weakness

What are the risk factors for aneurysms?

1. smoking

2. HTN

3. atherosclerosis

4. old age

How are aneurysms classified?

By shape:

• fusiform = dilation affecting entire circumference of artery

• saccular = outpouching affect distinct portion of artery

By location:

• abdominal aortic aneurysm (AAA) = abdomen

• thoracic aortic aneurysm (TAA) = chest

What is a complication of aneurysms?

rupture → hemorrhage → shock → death

What is an abdominal aortic aneurysm (AAA)?

most aneurysms, commonly asymptomatic, and frequently rupture

Types:

• stable AAA

• ruptured AAA

What is the patho of AAAs?

1. weakening of aortic wall

2. aneurysm formation

3. progressive enlargement

4. increased wall stress

5. risk of rupture

Where are most AAAs and how are they discovered?

infrarenal = occurs below the kidneys; discovered incidentally (through exam or imaging for another reason)

What are the manifestations of stable AAA?

1. often asymptomatic

2. pulsatile abdominal mass, detectable at least 5 cm diameter

3. abdominal, flank, or back pain

   • steady w/ gnawing quality

   • unaffected by movement

   • lasting for hours or days

   • assess pain if impending rupture is suspected

What are the manifestations of ruptured AAA?

1. sudden severe abd/back pain

2. hypotension

3. tachycardia

4. diaphoresis

5. decreased LOC

6. oliguria

7. loss of pulses distal to rupture

8. dysrhythmias

9. hypovolemic shock = critical!!

What are the warning signs of a suspected AAA rupture and what are the nursing priorities?

1. sudden severe abdominal, flank, or back pain

   • sharp, tearing, ripping, or stabbing movement from origin

2. diaphoresis & pallor

3. N/V

4. rapid, weak pulse, hypotention

5. anxiety apprehension

What are the nursing priorities for a suspected ruptured AAA?

1. notify provider immediately

2. monitor for shock

3. maintain IV access

4. prepare for emergency surgery

5. monitor distal perfusion

6. assess urine output

7. monitor for hemorrhage

8. maintain hemodynamic stability

   • ex: cardiopulmonary bvpass machine

What diagnostic tests are used for initial evaluation for AAA?

abdominal ultrasound

1. first-line test

2. measures aneurysm diameter

3. used for surveillance

What diagnostic tests are used for a detailed evaluation for AAA?

CT angiography

• defines size and extent

• detects rupture

• used before repair

MRA

• alternative imaging option

Angiography

• interventional imaging

• used during vascular procedures

What management is used for stable AAA?

• Prevention/reduction:

  • smoking cessation

  • BP control

  • statins

  • CV risk reduction

• Surveillance:

  • serial abdominal US → aneurysm size & growth

• Surgery/repair

When should you consider repair for AAA?

1. symptomatic

2. rapidly enlarging

3. large aneurysm > or = 6cm

4. rupture

What are the repair options for AAA?

1. open surgery (synthetic graft i.e., Dacron) placement

   • more invasive and longer recovery

2. endovascular aneurysm repair/EVAR (stent graft placement)

   • less invasive and shorter recovery

What pt teaching is needed for stable AAA and post-repair?

Stable:

• BP control

• smoking cessation

• med adherence

• follow-up US/CT surveillance

Post-op:

• avoid heavy lifting >15-20 lbs

• avoid pulling, pushing, or straining

• follow activity restrictions (no climbing stairs)

• keep follow-up appts

Report if:

• sudden abd/flank/back pain

• dizziness, syncope

• signs of infection

• changes in LE circulation

What is aortic dissection (AD)?

life-threatening dissecting hematoma; caused by sudden tear in aortic intima → blood enters aortic wall

What is the patho of AD?

1. intimal tear

2. blood enters vessel wall

3. false lumen forms

4. decreased distal perfusion

5. increased rupture risk

What are the complications of AD?

• organ ischemia

1. shock

2. aortic rupture

3. death

What are the risk factors for AD?

1. HTN (most common)

2. atherosclerosis

3. connective tissue disorders

What are the manifestations of AD?

Classic S/S:

1. sudden severe chest/back pain = tearing, ripping sharp

   • can migrate as dissection progresses

2. Decreased perfusion findings:

   • syncope & altered LOC

   • pulse deficits (unequal pulses)

   • unequal arm BPs

3. Organ ischemia

   • cerebral, myocardial, renal, or mesenteric ischemia

What is the diagnostic testing used in the initial eval of AD?

1. ECG → r/o MI

2. CXR → may show widened mediastinum

What diagnostic testing is used in definitive imaging of AD?

1. CT angiography (CTA) → most common

2. TEE → for unstable pts

3. MRI → highley accurate but less practical in emergencies

What tx is used for AD?

Medication:

• IV beta blockers (first-line)

• BP control

• pain management → reduces aortic wall stress

Surgical:

• for ascending thoracic AD (Stanford TYpe A dissection)

• rupture

• organ ischemia

What nursing interventions are used for AD?

1. continuous BP monitoring

2. pulse assessment

3. neuro assessment

4. pain control

5. monitor urine output

6. prepare for surgery