Arterial disorder

Arteriosclerosis- hardening of arteries.

Lining of the way and small arteries become thick.

Atherosclerosis- lipid, fats calcium carbohydrate, blood and fibrous tissues build in the layer of the arteries(Plaque)

  • narrowing, obstruction by thrombus, aneurysm, ulcerations, and rupture in the arteries

  • Ischemic and necrosis of the tissue

  • Can occur anywhere in the arteries

  • Platelets accumulate in response to the rupture in the artery wall causing them to clump leading to thrombosis

  • Thrombosis dislodge- emboli

  • Create fatty streaks in artery and fibrous plaque


Modifiable Risk

  • diabetes- speed up atherosclerotic thinking small and large vessel

  • Diet

  • Elevated CRP

  • Hyper homocysteine

  • Hyperlipidemia

  • Hypertension

  • Nicotine- cause vasospasm and vasoconstriction

  • Inactive lifestyle

  • Stress

Non modifiable

  • age

  • Sex

  • Family history

  • Genetics

  • Eclampsia


#1 cause is Tobacco and nicotine

  • decrease blood flow cause vasoconstriction

Increase risk for clot formation

  • Carbon monoxide in blood then oxygen - tissue is not receiving oxygen

  • Increase ldl and cholesterol and decrease hdl

DIABETES

  • increase the risk of PAD two to four folds

  • Amputation 8 times higher

-Inflammation process, derangement of cells, coagulation, inhibit fibrinolysis

Lack of exercise, obesity and stress also contribute to this disease process

CRP-

- tell cardiovascular inflammation

  • Risk for vascular damage especially when associated with age. hypertension hyper cholesterol obesity and elevation of glucose, nicotine, and family history of cvd.

Hyperhomocysteine

  • risk of peripheral, cerebrovascular disease, coronary artery disease and vte

  • Homocysteine promote coagulation by depressing protein c activation and increase fibrin

Prevention

  • Change diet decreasing fat and exercise to reduce lipids

  • Statins- 1st line therapy in PAD for secondary prevent and cardiovascular risk

  • Bile acid- cholestyramine, colesevelam, colestipol

  • Nicotinic acid (niacin)

  • Fibrin acid inhibitors (Gemfibrozil; fenofibrate)

Ezetimibe( cholesterol)

Improve by exercising, changing diet, medication therapy, and surgery

Endovascular- incision to invert catheter for diagnosis imaging or to deliver therapy such as a stent, balloon, med into the blood vessels

Management: establish inflow to distal vessels; pt recurrent disease, residential for restenosis, must be able to take anti platelets meds for 6 months

Arteriosclerosis- hardening of arteries.

Lining of the way and small arteries become thick.

Atherosclerosis- lipid, fats calcium carbohydrate, blood and fibrous tissues build in the layer of the arteries(Plaque)

  • narrowing, obstruction by thrombus, aneurysm, ulcerations, and rupture in the arteries

  • Ischemic and necrosis of the tissue

  • Can occur anywhere in the arteries

  • Platelets accumulate in response to the rupture in the artery wall causing them to clump leading to thrombosis

  • Thrombosis dislodge- emboli

  • Create fatty streaks in artery and fibrous plaque


Modifiable Risk

  • diabetes- speed up atherosclerotic thinking small and large vessel

  • Diet

  • Elevated CRP

  • Hyper homocysteine

  • Hyperlipidemia

  • Hypertension

  • Nicotine- cause vasospasm and vasoconstriction

  • Inactive lifestyle

  • Stress

Non modifiable

  • age

  • Sex

  • Family history

  • Genetics

  • Eclampsia


#1 cause is Tobacco and nicotine

  • decrease blood flow cause vasoconstriction

Increase risk for clot formation

  • Carbon monoxide in blood then oxygen - tissue is not receiving oxygen

  • Increase ldl and cholesterol and decrease hdl

DIABETES

  • increase the risk of PAD two to four folds

  • Amputation 8 times higher

-Inflammation process, derangement of cells, coagulation, inhibit fibrinolysis

Lack of exercise, obesity and stress also contribute to this disease process

CRP-

- tell cardiovascular inflammation

  • Risk for vascular damage especially when associated with age. hypertension hyper cholesterol obesity and elevation of glucose, nicotine, and family history of cvd.

Hyperhomocysteine

  • risk of peripheral, cerebrovascular disease, coronary artery disease and vte

  • Homocysteine promote coagulation by depressing protein c activation and increase fibrin

Prevention

  • Change diet decreasing fat and exercise to reduce lipids

  • Statins- 1st line therapy in PAD for secondary prevent and cardiovascular risk

  • Bile acid- cholestyramine, colesevelam, colestipol

  • Nicotinic acid (niacin)

  • Fibrin acid inhibitors (Gemfibrozil; fenofibrate)

Ezetimibe( cholesterol)

Improve by exercising, changing diet, medication therapy, and surgery

Endovascular- incision to invert catheter for diagnosis imaging or to deliver therapy such as a stent, balloon, med into the blood vessels

Angoplasty- lesions cut or laser away by PTA or atherectomy

  • local anesthesia, balloon tip catheter across stenosis area

  • Widen artery and allow blood to flow

Atherectomy and pTA s/e

  • hematoma

  • Embolus - blood fat air travel Ang dislodge in vein

  • Dissection - separation of vessel, occlusion, bleeding

  • Stents reduce risk of restenosis

  • Bleeding

Goal to improve PAD

Improve circulation promote vasodilation, prevent compression, manage plan, maintain tissue integrity

Circulation

Position the body part broke the level of the heart

Ex- lower extremities; elevate pat head or have the pt to use the recliner chair or sit with feel resting on the floor

  • walking and exercise to promise blood flow or isometric exercise that promote blood flow and circulation

The amount of exercise before pain give baseline

  • instruct patient to walk into pain starts, rest, and walk again once stops - increase circulation

  • Pain indicate lack of oxygen to tissues

Prescribe SET program to pat with claudication; consult physician first


Promote vascular and prevent compression

  • Increase blood flow to the extremities by arterial dilation

  • Warmth to promote arterial flow avoid cold ( vasoconstriction)

  • Wear adequate clothing

  • Test temp of bath water and avoid the use of heating pad; can be applied to the abdomen which can provide reflex vasodilation to arteries in extremities

  • Raynauds disease apply heat directly usu bf a warmer or electric blanket; do not exceed body temperature

  • Use heating pad with caution

  • Stop smoking

Minimize stress cause vasoconstriction

  • counseling, yoga, relaxation, aromatherapy, mindfulness and counseling

  • No tight clothing.socks or shoe laces- promote venous stasis and impede circulation

Do not cross legs for more that 15 minutes

Pain

Chronic and continue and disabling

Disturb sleep rest and overall quality of life

Give pain meds to assist

Tissue integrity

PAD and diabetes- at risk for infections and damage my tissues

Delayed healing and poor blood sipped

Non healing ulcers

Risk for amputation of ischemic toe ex forefoot, or limbs

Avoid trauma to extremities

Wear study and well forties shoes or slippers to prevent injury

Use neutral soaps and body lotions to prevent dry skin and cracking.

Do not apply lotion between toes don’t scratch or rub vigorously - abrasion lead to infection

Feet should be pasted dry not rubbed

Wear clean dry stockings

Fingernails and toes trimmed straight

Shoe inserts to prevent callous

Report all foot problems to HCP

Nurse need to exam lowers extremities of doable patients

Promote good inhibition to asst with healing and prevent skin breakdown

Adequate protein and vitamins need for arterial insufficiency

Low fat diet and lipids with atherosclerotic


Elderly

  • first sign limb ischemia and gangrene

  • Circulation decreased

  • Gangrene cause minimal arterial flow by edema

Intermittent claudication occur after walking only half to one blank and upstairs


Foot and leg care

Wash between the toes and don’t apply lotion

Rinse and pat dry

Wear loose clean cotton socks allow air circulation and wick moisture

No heating pads and hot tubs, avoid sun burn

Inspection feet with mirror daily for redness dryness cuts and blister, wear soft shoes or slippers

Podiatrist for vision impaired

House paths clear to prevent inju try no open toe shoes

Foam between toles that overlap or retain moist

Wear leather shoes

Avoid compression by tight stockings

No smoking and walk regularly

Contact provider for any foot or leg issues

Use only meds given by dr

PAD

Legs are affected


Common in women than men

S/s; immediate Claudia cation: aching, cramping and biting or fatigue and weakness with exercise and activity veered with rest, coldness and numbers of extremity

Pain distal from the of stenosis and occlusion

Decrease ability to walk distance as before and pain with ambulation

Severe- rest pain; worse at night; hang leg over bed side or sleep in recliner

Pain due to ischemia ( persistent, aching, or boring pain)

Unrelieved my opioids and disabling


Diagnosis:

  • coldness and numbness of the extremities with claudication

  • Cool to touch and pale when elevated

  • Ruddy and cyanotic in dependent position

  • Thickness of nails and opaque,keratin, gangrene, and muscle atrophy

  • Bruits heard and pulses absent or dimished

  • EXAMINE PERIPHERAL PULSES; abnormal or absent = PAD

  • Skin shiny, atrophied, and dry; sparse or absent hair

  • Compare right and left

Use CW Doppler and ABI and treadmill test and duplex

SET program is helpful to improve

Meds: Cilostazol- vasodilator that inhibits platelets formation and true claudication

  • decrease hyperplasia after angioplasty and stent if

  • Improve walking distance

  • DO NOT GIVE TO PATIENTS WITH HF

  • Give asking and plavix decrease cardiac events, limb loss after revascularization

  • Statins- improve endothelial function

SURGERY

FOR REST PAIN, severe and disabling clarification or at risk limb necrosis

-Bypaas Graft

  • reroute blood flow around stenosis it occlusion

  • - Before determine when the site of vessel joined with be located ; vessel must be 50% parent for graft to remain open

  • Below- inguinal ligament - FEMORAL TO POPLITEAL GRAFT - above and below the knee graft - location of anastomosis

  • - use synthetic woven or knitted Dacron it polytrafluoroethylene or Autogous Conduit( own vien)

  • - vien placed in heparin solution to check for leaks and competency and to prevent it from being Dria fn brittle during operation

  • Can’t tolerate vascular surgery amputation

  • Post op: maintain circulation, check p’s, cap refill, sensory and motior function compare to both: every 15 mines and them stable time increases.

  • ABI check q 8hr h 24 hr and each day until discharge; stay is usually 3-5 days

  • Establish and maintain circulation

  • Pulse disappear- THROMBOTIC OCCLUSION OF GRAft- immediate surgery

  • Monitor Urine output. Central venous pressure, mental status, pulse and volume

  • Bleeding can occur from heparin: hematoma may form

  • Review report to determine heparin reversal (Protamine sulfate) antidote

  • Avoid crossing legs and prolong dependent position to prevent thrombosis

  • Edema expected and normal

    - can be reduce by encourage bed exercise and elevation

  • Stocking and compression maybe supply avoid compression on bypass graft

Severe edema pain and decrease sensation can indicate compartment syndrome

AORTOILIAC DISEASE

  • with colllateral circulation pt with stenosis and/ or occlusion c/o buttock it low back discomfort associated with walking or asymptomatic

  • Erectile dysfunction and impotence occurs

  • Decrease or absent femoral pulse

  • Medical

  • Endovascular procedure - bilateral iliac stent, if not responsive to medical treatment

  • Aortic disease- aortoilloac graft

  • - performed within the abdomen

  • - illiquid vessels occluded - femoral arteries ( artobifemoral graft) femoral demote crossover graft needed to maintain circulation

- bifurcated woven or knitted Dacron graft preferred

Nursing

Preop

  • Evaluation of brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis pulse to eat baseline for follow up

Discuss procedure, expectation, pt sign sound and sensation

PostOp Endovascular

  • monitor for thrombosis in arteries distal to the sore

  • Assess color and temp, cap refill time, sensors and motor function, palpate pulses and Doppler every 15 mins and then longer once stable

  • Disappearance if pulse it Doppler sign, any dusky blue discoloration, coldness, decrease sensation or motor function, decrease pulse quality - REPORT IMMEDIATELY

Post op Care

  • Monitor urine output ( at least the 0.5 ml/kg/h

  • Kidney function impaired hypo-perfusion from hypertension, ischemia to renal, hypovolemia, or embolism of renal artery or renal parenchyma

  • Monitor vitals, pain, i &ovary monitored with the pulse and extremities assessment

  • Monitor lab and report to provider

  • Assess bowel sounds and paralytic ileus at every 8 hours

  • Bowel sounds may not return until about 3rd postop day

  • Absent bowel function and abdomen dissection indicated paralytic ileus

  • Bruising result of from decrease peristalsis

  • NG suction to decompress the bowel until persists low return

  • Liquid movement before the 3rd day indicate bowel ischemia when blood supply is occluded

  • Ischemic bowel increases pain and elevated wbc


-

Aneurysms

  • localized sac or dilation formed at weak point into wall of artery.

  • Classified by shape or form

  • Most common: secular ( projects to only one side of the vessel) and fusions ( arterial segment become dilated)

  • Very small aneurysms- Mycotic

    Two Types: Aortic and Thoracic

  • Abdominal aortic aneurysms occur from degenerative aneurysms

  • Large vessels rupture- hemorrhage and death

    Thoracic

  • Cause by atherosclerosis

  • More frequently in males between 50 and 70 years old

  • Most common: Dissecting Aneurysm

    S/S:

  • Pain constant and boring

  • Only occur in supine position

Sob, pressure against trachea, cough ( paryosmal and brassy, hoarseness, strider, or vocal wekaness ( aphonia ), pressure against laryngeal nerve, dysphagia ,

Diagnosis:

  • chest neck or arms veins dilated, edema around the chest wall and cyanosis

  • Pressure on cervical and unequal pupils

Chest xray, cat, Mrs, tee

Treatment

  • Control BP

  • Systolic bp should remain between 90-120mmHG

  • Maintain mean arterial pressure between 65-75 ( beta blockers and hydralazine

  • Sodium nitroprusside- emergent lover bp ; give IV continuously

  • Surgery to repair with vascular graft and restore vascular continuity

  • Intense monitoring

  • Prepare thoracic aneurysms using Endovascular grafts placed percutaneously

  • - combine interventional suite and operating room decrease recovery time she decrease complications

  • Complication risk: spinal cord ischemia and paraplegia

  • - place lumbar drains placed ; improve spinal perfusion

  • Maintain Csf pressure less than or equal to 10mmHG and mean MAP greater than 90 for the first 36-48 hrs to prevent neuro deficits


  • non

- lesions cut or laser away by PTA or atherectomy

  • local anesthesia, balloon tip catheter across stenosis area

  • Widen artery and allow blood to flow

Atherectomy and pTA s/e

  • hematoma

  • Embolus - blood fat air travel Ang dislodge in vein

  • Dissection - separation of vessel, occlusion, bleeding

  • Stents reduce risk of restenosis

  • Bleeding

Goal to improve PAD

Improve circulation promote vasodilation, prevent compression, manage plan, maintain tissue integrity

Circulation

Position the body part broke the level of the heart

Ex- lower extremities; elevate pat head or have the pt to use the recliner chair or sit with feel resting on the floor

  • walking and exercise to promise blood flow or isometric exercise that promote blood flow and circulation

The amount of exercise before pain give baseline

  • instruct patient to walk into pain starts, rest, and walk again once stops - increase circulation

  • Pain indicate lack of oxygen to tissues

Prescribe SET program to pat with claudication; consult physician first


Promote vascular and prevent compression

  • Increase blood flow to the extremities by arterial dilation

  • Warmth to promote arterial flow avoid cold ( vasoconstriction)

  • Wear adequate clothing

  • Test temp of bath water and avoid the use of heating pad; can be applied to the abdomen which can provide reflex vasodilation to arteries in extremities

  • Raynauds disease apply heat directly usu bf a warmer or electric blanket; do not exceed body temperature

  • Use heating pad with caution

  • Stop smoking

Minimize stress cause vasoconstriction

  • counseling, yoga, relaxation, aromatherapy, mindfulness and counseling

  • No tight clothing.socks or shoe laces- promote venous stasis and impede circulation

Do not cross legs for more that 15 minutes

Pain

Chronic and continue and disabling

Disturb sleep rest and overall quality of life

Give pain meds to assist

Tissue integrity

PAD and diabetes- at risk for infections and damage my tissues

Delayed healing and poor blood sipped

Non healing ulcers

Risk for amputation of ischemic toe ex forefoot, or limbs

Avoid trauma to extremities

Wear study and well forties shoes or slippers to prevent injury

Use neutral soaps and body lotions to prevent dry skin and cracking.

Do not apply lotion between toes don’t scratch or rub vigorously - abrasion lead to infection

Feet should be pasted dry not rubbed

Wear clean dry stockings

Fingernails and toes trimmed straight

Shoe inserts to prevent callous

Report all foot problems to HCP

Nurse need to exam lowers extremities of doable patients

Promote good inhibition to asst with healing and prevent skin breakdown

Adequate protein and vitamins need for arterial insufficiency

Low fat diet and lipids with atherosclerotic


Elderly

  • first sign limb ischemia and gangrene

  • Circulation decreased

  • Gangrene cause minimal arterial flow by edema

Intermittent claudication occur after walking only half to one blank and upstairs


Foot and leg care

Wash between the toes and don’t apply lotion

Rinse and pat dry

Wear loose clean cotton socks allow air circulation and wick moisture

No heating pads and hot tubs, avoid sun burn

Inspection feet with mirror daily for redness dryness cuts and blister, wear soft shoes or slippers

Podiatrist for vision impaired

House paths clear to prevent inju try no open toe shoes

Foam between toles that overlap or retain moist

Wear leather shoes

Avoid compression by tight stockings

No smoking and walk regularly

Contact provider for any foot or leg issues

Use only meds given by dr

PAD

Legs are affected


Common in women than men

S/s; immediate Claudia cation: aching, cramping and biting or fatigue and weakness with exercise and activity veered with rest, coldness and numbers of extremity

Pain distal from the of stenosis and occlusion

Decrease ability to walk distance as before and pain with ambulation

Severe- rest pain; worse at night; hang leg over bed side or sleep in recliner

Pain due to ischemia ( persistent, aching, or boring pain)

Unrelieved my opioids and disabling


Diagnosis:

  • coldness and numbness of the extremities with claudication

  • Cool to touch and pale when elevated

  • Ruddy and cyanotic in dependent position

  • Thickness of nails and opaque,keratin, gangrene, and muscle atrophy

  • Bruits heard and pulses absent or dimished

  • EXAMINE PERIPHERAL PULSES; abnormal or absent = PAD

  • Skin shiny, atrophied, and dry; sparse or absent hair

  • Compare right and left

Use CW Doppler and ABI and treadmill test and duplex

SET program is helpful to improve

Meds: Cilostazol- vasodilator that inhibits platelets formation and true claudication

  • decrease hyperplasia after angioplasty and stent if

Improve walking distance

Aneurysms

  • localized sac or dilation formed at weak point into wall of artery.

  • Classified by shape or form

  • Most common: secular ( projects to only one side of the vessel) and fusions ( arterial segment become dilated)

  • Very small aneurysms- Mycotic

    Two Types: Aortic and Thoracic

  • Abdominal aortic aneurysms occur from degenerative aneurysms

  • Large vessels rupture- hemorrhage and death

    Thoracic

  • Cause by atherosclerosis

  • More frequently in males between 50 and 70 years old

  • Most common: Dissecting Aneurysm

    S/S:

  • Pain constant and boring

  • Only occur in supine position

Sob, pressure against trachea, cough ( paryosmal and brassy, hoarseness, strider, or vocal wekaness ( aphonia ), pressure against laryngeal nerve, dysphagia ,

Diagnosis:

  • chest neck or arms veins dilated, edema around the chest wall and cyanosis

  • Pressure on cervical and unequal pupils

Chest xray, cat, Mrs, tee

Treatment

  • Control BP

  • Systolic bp should remain between 90-120mmHG

  • Maintain mean arterial pressure between 65-75 ( beta blockers and hydralazine

  • Sodium nitroprusside- emergent lover bp ; give IV continuously

  • Surgery to repair with vascular graft and restore vascular continuity

  • Intense monitoring

  • Prepare thoracic aneurysms using Endovascular grafts placed percutaneously

  • - combine interventional suite and operating room decrease recovery time she decrease complications

  • Complication risk: spinal cord ischemia and paraplegia

  • - place lumbar drains placed ; improve spinal perfusion

  • Maintain Csf pressure less than or equal to 10mmHG and mean MAP greater than 90 for the first 36-48 hrs to prevent neuro deficits