Study Notes for Vascular Disorders in Nursing

F.A. Davis Advantage for Medical-Surgical Nursing - Chapter 31: Coordinating Care for Patients With Vascular Disorders

Peripheral Arterial Disease (PAD)

Overview
  • Definition: Narrowing of arteries supplying peripheral tissues and organs, excluding the heart and brain.
  • Epidemiology: Affects approximately 8.5 million people in the United States.
  • Clinical importance lies in its role in ischemic conditions, leading to insufficient blood supply to tissues.
Risk Factors for PAD
Non-Modifiable Factors
  • Increasing age
  • Male sex
  • Family history of PAD
Modifiable Factors
  • Smoking
  • Obesity
  • Sedentary lifestyle
Predisposing Conditions
  • Diabetes Mellitus
  • Dyslipidemia (high cholesterol)
  • Hypertension
Specific Risk Indicators
  • High cholesterol levels (>200 mg/dL)
  • High triglycerides (>150 mg/dL)
  • High LDLs (>100 mg/dL)
  • Low HDLs (<40 mg/dL)
Pathophysiology
  • Most common cause of PAD is atherosclerosis, characterized by:
    • Buildup of fatty and fibrous material beneath the inner lining of blood vessels, forming plaque.
    • This buildup narrows the lumen of arteries, reducing perfusion to tissues.
  • Condition can worsen due to embolism:
    • A blood clot or fatty deposit can obstruct narrow peripheral arteries, blocking blood flow.
Clinical Manifestations
Key Symptoms
  • Ischemic muscle pain (intermittent claudication): Seen mainly in the legs due to reduced blood supply.
    • Pain presents as cramping, typically in the calves, thighs, or buttocks during physical activities (walking/exercise) but may be asymptomatic at rest.
  • As PAD worsens:
    • Continuous burning or pain in the forefoot and toes when elevated, relieved when lowered.
    • Foot might exhibit a reddish discoloration upon being lowered ("dependent rubor").
Additional Symptoms
  • Paresthesia (numbness or tingling sensation)
  • Cold extremities
  • Atrophy of muscles
  • Hair thinning or loss
  • Skin color changes, pallor, or cyanosis when elevated (elevation pallor)
Advanced Symptoms of PAD
  • Critical limb ischemia includes 6 P's mnemonic:
    • Pain (burning pain)
    • Pallor (pale skin)
    • Pulselessness (absence of pulse)
    • Paralysis (loss of movement)
    • Paresthesia (numbness)
    • Perishingly cold (cold extremities).
Diagnosis of PAD
  • Key Diagnostic Tools:
    • History and physical examination to assess symptoms.
    • Ankle-Brachial Index (ABI): Measures the ratio of blood pressure in the ankle to blood pressure in the arm to determine severity:
    • >1.3 = Cardiovascular disease
    • 1.0 - 1.29 = Normal
    • 0.91 - 0.99 = Borderline
    • 0.41 - 0.90 = Mild to moderate PAD
    • <0.40 = Severe PAD
    • Listening to pulse with a stethoscope to detect bruits (whooshing sounds in narrowed arteries).
    • Doppler ultrasound to visualize blood flow.
    • In rare cases, angiography may be used to confirm the diagnosis via X-rays and contrast agents assessing blood flow.
Treatment of PAD
Medical Management
  • Lifestyle Changes:
    • Quit smoking.
    • Lose weight.
    • Adopt a healthy diet.
    • Regular exercise to manage symptoms and improve circulation.
Medications
  • Antiplatelet medications:
    • Aspirin or Clopidogrel to reduce the risk of clotting.
  • Statins: To manage cholesterol levels (e.g., Atorvastatin, Simvastatin).
    • Monitor cholesterol levels, liver function, signs of rhabdomyolysis (muscle pain).
  • Antihypertensive medications:
    • Manage blood pressure (e.g., Lisinopril) and monitor for side effects.
Surgical Management
  • Revascularization Procedures:
    • Percutaneous interventions such as angioplasty or stenting.
    • Surgical bypass to re-establish arterial blood flow.
  • If gangrene occurs: removal of necrotic tissue or limb amputation may be necessary.
Nursing Management
  • Nursing Diagnoses:
    • Risk for ineffective tissue perfusion.
    • Pain management needs.
  • Interventions:
    • Education about lifestyle changes, daily foot care, and recognizing symptoms requiring urgent medical attention.
    • Collaboration with multidisciplinary teams for specialized care.

Burger Disease (Thromboangiitis Obliterans)

  • Definition: Inflammation of small blood vessels primarily affecting hands and feet, predominantly in men aged 20-45 who are heavy smokers.
  • Symptoms:
    • Affects multiple limbs.
    • Pale, red, or blue extremities cold to touch.
    • Burning or tingling sensation, especially exacerbated by cold and stress.
    • It may lead to painful ulcers and possibly amputation if untreated.

Raynaud's Syndrome

  • Demographics: More common in women under the age of 30.
  • Causes: Linked to drugs that constrict arteries, autoimmune diseases, or smoking.
  • Symptoms:
    • Affected areas turn white, then blue, generally with little to no pain, and later turn red upon blood flow restoration.
    • Symptoms can last from minutes to hours depending on the severity of exposure.
  • Treatment: Keeping warm, quitting smoking, and managing any potential skin ulceration.

Carotid Artery Disease

Overview
  • Epidemiology: Affects men more than women, with various risk factors similar to PAD.
Pathophysiology
  • Thickening of vessel walls with plaque formation occluding blood in carotid artery.
Clinical Manifestations
  • Patients may remain asymptomatic until cerebral perfusion is significantly impaired, leading to possible stroke or transient ischemic attack (TIA).
    • Symptoms of stroke include slurred speech, weakness, severe headache, sudden vision loss, and facial droop.
Diagnosis
  • Tools Used:
    • Carotid bruit detection.
    • Carotid duplex scan, CT angiography, MRI, and carotid angiography as potential confirmatory tests.
Classification of Severity
  • Mild: Less than 50% reduction in diameter.
  • Moderate: 50-69% reduction in diameter.
  • Severe: 70% or more reduction in diameter.
Management Options
Medical Intervention
  • Emphasis on lifestyle modifications and managing comorbid conditions.
  • Medications include anti-platelet therapy and statins.
Surgical Intervention
  • Carotid Endarterectomy: The first-line treatment for management of stroke risk and nerve damage.
  • Carotid Artery Stenting: An alternative to endarterectomy.
Nursing Interventions Post-Procedure
  • Continuous monitoring of respiratory rate, vital signs, cranial nerve function, and renal function post-surgery.
  • Maintain specified blood pressure parameters post-operatively and manage any fluctuations appropriately.

Deep Vein Thrombosis (DVT)

Epidemiology
  • Affects approximately 1 in 1,000 persons annually.
Risk Factors
  • Major influencing factors include increased age, cancer, prior venous thrombosis, immobility, obesity, and hormone therapy.
  • Virchow’s Triad:
    1. Slowed blood flow (stasis)
    2. Hypercoagulation (altered amounts of clotting factors)
    3. Damage to blood vessels
Clinical Manifestations
  • Developments of inflammation, pain, swelling, and redness; generally appear below the knee.
Diagnosis
  • Utilizing ultrasound, venography, and D-dimer tests to confirm the presence of a thrombus.
Treatment
  • Treatment for small clots may resolve spontaneously; larger clots may require intervention (thrombolysis, thrombectomy).
  • Longterm management involves anticoagulant medications such as Warfarin and Heparin to prevent pulmonary embolisms.
Nursing Management
  • Nursing Diagnoses: Ineffective tissue perfusion, acute pain, and risk for impaired mobility.
    • Interventions include teaching about recurrence prevention and compliance with medication regimens.

Chronic Venous Insufficiency (CVI)

Epidemiology
  • Primary CVI: Results from progressive venous wall dilation (70%).
  • Secondary CVI: Response to events like DVT (30%).
Pathophysiology
  • Results from venous wall dysfunction leading to blood pooling, increased venous pressure, and edema.
Clinical Findings
  • Signs include pain, swelling, brownish discoloration, and potential for ulceration and sores.
Diagnosis
  • Based on history, physical exams, venous ultrasound, and D-dimer blood tests.
Management
  • Emphasis on increasing activity levels and leg elevation.
  • Compression stocking use and possible surgical interventions (repairs and transplants).
Nursing Management
  • Nursing Diagnoses: Risk for infection, impaired mobility, and pain management.
    • Interventions must focus on teaching self-care, promoting healthy lifestyle changes, and managing complications.