INTER-MS WEEK 5 (chapter 26)

what is the function of the vascular system?

-provides circulatory needs to tissues

-in charge of blood flow and BP

-capillary filtration and reabsorption

older adult consideration for vascular disorders:

1) older adults may develop arteriosclerosis (hardened blood vessels)

2) have a decrease of blood going to tissues

3) left ventricular workload is increased

4) increased peripheral resistance (high BP)

5) they are more likely to develop HF

assessment for vascular disorders:

-obtain health hx: history of intermittent claudication? etc.

-assess skin: cool/pale/pallor, loss of hair, brittle nails, and dry skin (all signs of decreased vascular function)

-check pulses-especially distal pulses on lower extremities (weak/diminished= poor circulation)

what is intermittent claudication?

Leg pain that is brought on by exercise and relieved by rest. It is characteristic of peripheral artery occlusion/ arterial insufficiency. It is dull or cramp like and consistently occurs in the same area of the leg and with same amount of distance.

what are the diagnostic tests for vascular disorders?

-Doppler ultrasound flow test (detects blood flow)

-Ankle brachial index (noninvasive way to compare the difference b/w arm pressure/ankle pressure)

-exercise (stress) test

-Duplex ultrasonography (noninvasive; uses sound waves to evaluate blood flow through body)

-CT

-angiography/MRI (to visualize obstructions/blocks)

peripheral vascular disease:

Vascular diseases affecting blood vessels outside of the heart

(especially the vessels supplying the extremities)

arterial vascular disease signs:

-intermittent claudication (leg pain with exercise)

-edema

-no/weak pulse

-no drainage from sores

-round/smooth sores

-causes black eschar

-location of sores= toes/feet

venous ulcer signs:

-dull, achey pain

-lower leg edema

-present pulse

-drainage from sores (wheeping)

-irregular shaped sores

-yellow/reddened skin

-location of sores= ankles

arterial insufficiency

narrowing of arteries that causes inadequate blood flow

S/S: cramping pain and tired legs or hip muscles that subside with rest

**dangle legs, do NOT elevate for PAD

venous insufficiency

inadequate venous return of blood from the legs to the heart

S/S: tired/heavy/achey/cramping legs, pain that worsens while standing but improves with leg elevation (do NOT dangle legs)

risk factors for peripheral arterial disease (PAD)

-vascular insufficiency

-uncontrolled blood sugar in diabetics

-limited joint mobility

-improper footwear

risk factors for peripheral venous disease (PVD)

-varicose veins

-DVTs

-dysfunctional heart valves

-muscle weakness in legs

-immobility

-pregnancy

signs of PVD (peripheral venous disease)

-dry skin/eczema

-varicose/spider veins

-numbness/weakness

-swelling/aching in affected extremity

- hemosidurin (brown pigment that accumulates under skin from leaking red blood cells; it is painless)

signs of PAD (peripheral arterial disease)

-thin/shiny skin that is dry

-little to no hair on legs

-absent or weak pulses

what are the most common factors that can cause both PVD or PAD?

smoking, diabetes, high cholesterol, and hypertension

Peripheral arterial disease:

WHAT: progressive narrowing/degeneration of arteries

CAUSE: atherosclerosis

S/S: **intermittent claudication; thin/shiny dry skin, weak/no pulse, paresthesia (numbness), and thickened toenails

INTERVENTIONS: ACE inhibitors (ramipril), statins, anti platelets (aspirin and clopidogrel) all can be given; percutaneous angioplasty, laser-angioplasty, atherectomy, or arterial revascularization all may be performed; amputation is LAST (only if needed)

stages of PAD

stage 1= aysmptomatic

stage 2= intermittent claudication occurs

stage 3= resting pain occurs

stage 4= necrosis

what should you teach your patient on how they can improve their arterial circulation?

1) exercise: walk often and perform isometric exercises

2) DANLGE legs NOT elevate

3) no extreme temperatures (like heating pads; they may not feel it and can be burned)

4) no smoking

5) reduce stress levels

6) avoid tight clothing

nursing responsibilities/management for peripheral vascular disease patients:

-obtain vital signs (especially pulses)

-assess for pain often (OPQRST guideline)

-assess for bleeding often

-monitor for any post-op complications (infections etc.)

peripheral venous disease:

WHAT: progressive condition that affects the veins outside the heart

S/S: varicose/spider veins, pain/swelling in the legs or ankles, ulcers near the ankles, restless leg syndrome, achy/numb legs, and/or muscle spasms

INTERVENTIONS: anticoagulants/thrombolytics, cessation of smoking, weight loss, venous recanalization, endovenous ablation, or other minimally invasive procedures

arteriosclerosis vs. atherosclerosis:

arteriosclerosis= hardening of the arteries (most common disease of the arteries; often happens with older aged patients)

atherosclerosis= accumulation of lipids in the inner layer of the artery

(often you do not have one without the other)

upper extremity arterial disease:

WHAT: stenosis and occlusion in the upper extremities tart result from atherosclerosis or trauma

*occurs less frequently than in the lower extremities

S/S: arm fatigue, pain with exercise in extremity, and inability to hold or grasp objects

INTERVENTIONS: assessment of bilateral arm BPs, radial/ulnar/brachial pulse motor and sensory function monitoring, stent or stent graft placement may be performed or surgical bypass if needed

Aneurysms:

WHAT: a localized sac or dilation at a weak point in the wall of an artery

-classified by shape (different kinds)

types: dissecting aneurysm, abdominal aortic aneurysm, or thoracic aortic aneurysm

S/S: limb ischemia, diminished/absent pulses, cool/pale skin, pain

INTERVENTIONS: immediate surgery if an aneurysm is suspected; post-op= monitor for pain

Abdominal aortic aneurysm characteristics

steady flank pain in abdomen with a gnawing sensation; unaffected by movement

-may be described as a "heartbeat" in abdomen when lying down

-abdominal mass may be present

(may last hours or days)

thoracic aortic aneurysm characteristics

causes pain in the back/neck or substernal area; may cause dysphagia, dyspnea, and stridor or cough but is often asymptomatic

dissecting aneurysm characteristics

causes sudden/severe and persistent pain described as "tearing" or "ripping" in the chest and/or back

patient education for aneurysms:

-make sure to get routine physical exams

-teach s/s of impending rupture (low BP, rapid HR, and pain)

-self monitor BP (high BP is major risk for rupture)

-teach self- management with anticoagulants

Raynaud's disease:

WHAT: arterial occlusion of the fingertips and toes

S/S: sudden vasoconstriction which leads to color changes, pallor, and pain in fingertips/toes

INTERVENTIONS: teach patient to keep hands and feet warm and free from injury, to avoid stressful situations, and do not smoke

venous thrombosis

WHAT: formation of a blood clot within a vein

example: DVT

S/S: pain, swelling, warmth/redness, and SOB/chest pain

INTERVENTIONS: anticoagulants, thrombolytics, preventative measures (compression stockings, early ambulation, subQ heparin, and increased exercise/no smoking/weight loss); rest, elevate extremity, monitor for signs of PE (chest pain, rapid HR etc.), and thrombolectomy if surgery is needed

what is the Virchow's triad for venous thromboses?

these 3 factors contribute to the development of venous thrombosis:

1) endothelial damage: from smoking, HTN, surgery, or trauma

2) hypercoagulability: can be hereditary or acquired

3) stasis: from immobility or polycythemia

assessment of venous thrombosis

-assess for pain, redness, and edema

-keep in mind that DVTs are always unilateral

-assess by HOMAN's signs (flexing the calf and assessing pain)

patient education for patient's receiving thrombolytics:

-no IM injections

-use a soft bristle toothbrush

-do not take aspirin

varicose veins

WHAT: abnormally swollen and twisted veins, usually occurring in the legs

S/S: visible bulging veins, swelling legs, restless leg syndrome, and painful cramps

INTERVENTIONS: ambulate every hour, elevate foot of bed, and prevention through not crossing legs/sitting or standing for too long

COMPLICATIONS: hematoma formation, infections, and DVTs

lymphedema

WHAT: tissue swelling related to obstruction of lymphatic flow (abnormal accumulation of protein rich fluid)

S/S: swelling, pitting edema, fibrosis of skin, and pain/discomfort in affected area

INTERVENTIONS: no cure; decrease swelling by exercise, wrapping up arm or leg, massages, pneumatic compression, compression garments, and decongestive therapy

cellulitis

WHAT: bacterial skin infections that affects deeper layers of the skin and subcutaneous tissue

S/S: fever/chills, pain/tenderness, redness/swelling/warmth in affected area, and blisters

INTERVENTIONS: antibiotics, elevation of affected extremity, cool packs, educate about prevention, and skin/foot care daily

___________ causes a problem with blood flow back to the heart and leads to blood pooling in the legs

Peripheral venous disease

peripheral arterial disease is more severe than peripheral venous disease. True or false?

true (leads to ischemia and necrosis due to little/no oxygen)

P.A.D= B.A.D

acronym for PVD s/s

V- voluptuous pulses/warm legs

E-edema (blood pooling)

I-irregular shaped sores

N-no sharp pain (dull)

Y-yellow/brown ankles

acronym for PAD s/s

A- absent pulses ( leads to shiny/cool legs)

R- round/red sores

T-toes/feet have black eschar

S-sharp calf pain during activity ** (intermittent claudication)

the 6 P's of peripheral vascular disease assessment:

1) pain (is it unrelieved at rest?)

2) paresthesia (numbness/tingling)

3) pulses (weak/absent pulses)

4) pallor

5) polar (cold)

6) paralysis

what is the priority for the nurse to monitor in a patient with PAD?

ABC's

PVD= _______ legs

elevate

(to get pooling blood back to the heart)

PAD= ________ legs

dangle/hang

non-pharmacological treatment and patient education for PVD:

"8 C's"

1) careful with hot temperatures

2) cautious with foot trauma

3) constriction should be avoided

4) no constrictive clothing

5) no cigarettes

6) no caffeine

7) no cold temperatures

additionally:

-do a skin assessment DAILY

-shoes should be well fitted (no sandals)

-hydrate often to thin the blood

-toe nails should be trimmed (only by HCP)

_______________ causes cold ring fingers due to vasoconstriction of the tiny blood vessels in the fingers

Raynaud's

about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced. True or false?

true

what ankle brachial index (ABI) measurement is determined to be adequate for healing?

0.50 or more

Less than 0.5 = Severe arterial disease, poor healing potential

A client is readmitted to the facility with a warm, tender, reddened area on their right calf. Which contributing factor should the nurse recognize as most important?

recent pelvic surgery

(The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT)

The nurse is caring for a client with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?

lowering the limb so it is independent

A home health nurse is seeing an older adult client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

venous insufficiency

(Symptoms of venous insufficiency include present pedal pulses, edema, brown pigmentation in legs, irregularly shaped sores that are usually located around the ankles)

Characteristics of arterial insufficiency ulcers include:

circular/red sores, absent or weak pulses, black eschar (necrosis), and sores at tips of toes

The nurse knows which diagnostic test is used to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux?

duplex ultrasound scan

________________ involves injecting a radiopaque contrast agent into the venous system.

contrast phlebography

Chronic, nonhealing skin lesions are treated with what?

topical hyperbaric oxygen therapy

(This approach delivers oxygen above atmospheric pressure directly to the wound rather than to the full body as with other disorders such as carbon monoxide poisoning)

Signs of thoracic aortic aneurysm

dyspnea, stridor, hoarse voice, difficulty swallowing, and cough

About 75% of aneurysms occur in the abdominal aorta. True or false?

true

The nurse is caring for a client who is scheduled to have a vein ligation in the morning. How would the nurse describe a vein ligation to the client?

veins are tied off and left in the leg

A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following?

"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."

(It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature)

a _____________ is used to visualize arteries and veins and help assess for stenosis and occlusion.

Computed tomography angiography

The hallmark symptom of Raynaud syndrome is:

acute pain related to arterial insufficiency