Chapter 38: Nursing Management Vascular Disorders

Front 1

Vascular System

Back 1

Disorders of the arteries (oxygenated blood), veins (deoxygenated blood) and lympathic vessels.

Front 2

Peripheral Artery Disease Risk Factors

Back 2

Tobacco use, diabetes, hyperlipidemia, elevated CRP, and uncontrolled htn

Front 3

What is the leading cause of atherosclerosis?

Back 3

PAD

Front 4

Pulses, Edema, Hair, and Ulcer Location PAD

Back 4

Peripheral pulses decreased/absent, no edema, loss of hair on legs/feet/toes, and ulcers on tips of toes, foot/lateral malleous

Front 5

Margin/Drainage of PAD

Back 5

Rounded, smooth looks punched out, and minimal drainage

Front 6

Tissue of PAD Ulcer

Back 6

Black, eschar or pale pink granulation gangrene. Amputation may be required if blood flow not restored.

Front 7

Pain of PAD

Back 7

Intermittent claudication, pain in muscles (lack of O2), PAD of femoral/popliteal cause calf pain, PAD of iliac arteries cause buttock/thigh pain

Front 8

Nails, Skin color/texture and temp of PAD

Back 8

Nail thickened/brittle, skin color pallor develops w/ leg elevation, foot redness appers w/ limb in dependent position, skin texture is thin shiny, and taut, and temp is cool gradient down the leg. dermatitis and pruritus barely occur

Front 9

Dx studies of PAD

Back 9

Doppler ultrasound, angiography, ankle brachial index (divide ankle systolic by branchial systolic)

Front 10

Venous disease risk factors

Back 10

Venous stasis (age, a fib, immobility), endothelial damage (surgery, IV meds, fractures), hypercoagulatbility of blood (genetics, high altitudes, hormone therapy)

Front 11

Pulses, edema, hair and ulcer location of VD

Back 11

Peripheral pulses are present, lower leg edema, hair present/absent, ulcer near medial malleolus

Front 12

Margin/drainage of VD

Back 12

Irregularly shaped and moderate to large drainage

Front 13

Tissue of VD

Back 13

Yellow slough/dark red "ruddy" granulation,

Front 14

Pain w/ VD

Back 14

Dull ache/ heaviness in calf/thigh, ulcer often painful

Front 15

Nails, skin color, skin texture, temp and dermatitis and pruritus of VD

Back 15

Normal/thickened nails, skin color is bronze/brown pigmentation, varicose veins may be visible, skin thick hardened and indurated, skin is warm w/ no temp gradient, dermatitis/pruiritus occur often.

Front 16

Atherosclerosis skin color/temp/peripheral pulses

Back 16

Hyperemia in depedent position and pallor w/ elevation, skin texture is thin, shiny, taut, cool temp. Decreased/absent peripheral pulses

Front 17

If gangrene on foot where do you place Xs?

Back 17

On Dorsalis pedis and posterior tibial

Front 18

Nursing Planning/Intervention for PAD

Back 18

Assess pain, monitor extremeties for color, motion/sensation/pulses, obtain BP, assesss s/s of ulcer/gangrene.

Front 19

Teaching for PAD

Back 19

Stop all tobacco, avoid caffeine, aggressive tx of hyperlipidemia, BP less than 140/90, diabetes and renal failure 130/80. Walking most effective, avoid crossing legs, bmi and waist circumference. Dietary cholesterol, decreased intake of sat fat, sodium <2 g/day. avoid exposure to cold, never apply direct heat to limb.

Front 20

Drug therapy for PAD

Back 20

Antiplatelet agents and ACE inhibitors.

Front 21

Antiplatelet for PAD

Back 21

Considered critical. Aspirin 75-100 mg/day for symptomatic, 75-325 for asymptomatic, Clopidogrel (Plavix) daily. Combining Plavix and asa are typically not recommended but is okay for symptomatic PAD

Front 22

What should Plavix not be used w/ for increased risk for stroke/MI?

Back 22

Omeprazole (Prilosec) PPI

Front 23

First line drug treatment for intermittent claudication

Back 23

Cilostazol (Pletal) and pentoxifylline (Trental)

Front 24

When are Cilostazol (Pletal) and pentoxifylline (Trental) contraindicated?

Back 24

HF

Front 25

Interventional radiologic procedures for PAd

Back 25

Peripheral artery bypass operation w/ autogenous vein or synthetic graft material to bypass or carry blood around the lesion

Front 26

What kind of care is very important to teach PAD pts?

Back 26

Meticulous foot care

Front 27

Complications of PAD

Back 27

It progresses slowly. Leads to atrophy of skin and underlying muscles. Minor trauma can result in delayed healing, wound infection, and tissue necrosis. Arterial ischemic ulcers occur most often over bony promineces. Amputtation may be needed if adeqate blood flow is not restored. Uncontrolled pain/severe spreading infection are indicators that an amputation is needed

Front 28

Acute Intervention of PAD

Back 28

After surgery/radiologic intervention to extremity: Check extremity Q15M intially for color, temp, cap refill, presence of peripheral pulses, and sensation and movement.

Front 29

Acute arterial Ischemia

Back 29

Sudden interruption in the arterial blood supply to a tissue, organ or extremity that if utnreated results in tissue death

Front 30

Common Cause of acute arterial ischemia

Back 30

embolism, thrombosis, or trauma

Front 31

Tx of acute arterial ischemia include?

Back 31

Anticoagulation, thrombolysis, embolectomy, surgical revascularization or amputation.

Front 32

Thromboangitis obliterans (Buerger's disease)

Back 32

Occlusive disease of the median and small arteries and veins. Distal and upper and lower limbs affected most commonlny

Front 33

Occurs mostly in what gender and age group

Back 33

Young men <45 y/o long hx of tobacco/marijuana use and chronic peridontal infection w/out other CVD risk factors

Front 34

Dx tests and labs for Buerger's disease

Back 34

None

Front 35

Plans/Interventions for Buerger's disease

Back 35

Smoking cessation, monitor pulses, avoid injury, adminster vasodilators, instruct on med therapy. Surgical options: revascularization, implantation of spinal cord stimulator

Front 36

Raynaud's Phenomenon may be related to what?

Back 36

Rheumatoid arthritis

Front 37

S/S of Raynaud's phenomenon

Back 37

Vasospasm (Color changes on fingers, toes, ears, or nose) (White blue red). coldness or numbness in vasconstrictive phase, then throbbing aching pain, tinging and swelling in hyperemic phase, episodes last only minutes by increased w/ cold, emtional upset, caffeine and tobacco use.

Front 38

Dx test of Raynaud's phenomenon

Back 38

None, based on persistent symptoms for at least 2 years.

Front 39

Patient teaching Raynau'ds phenomenon

Back 39

Mintor pulses, tell pt to wear loose warm clothing, avoid temp extremes, stop using tobacco and avoid caffeine, avoid injury to hands/fingers

Front 40

Most common problem affecting aorta

Back 40

Aneurysm

Front 41

3/4 of aneurysms occur in the _____ ______ and 1/4 occur in the ______ ______

Back 41

Abdominal aorta, thoracic aorta

Front 42

Risk factors for aortic aneurysms

Back 42

Age, male, caucasian, family hx, htn, CAD, previous stroke, obestiy and tobacco use

Front 43

True Aneurysm

Back 43

Aneurysm in which one of three later vessel of the aneurysm is intact

Front 44

False aneurysm

Back 44

Not an aneurysm but a disruption of all arterial wall layers w/ bleeding that is contained by surrounding automic structures

Front 45

S/S of abdominal aortic aneurysm

Back 45

Pulsating mass in abdominal systolic bruit over aorta, tenderness of deep palpation abd or lower back pain, changes in bowel habits

Front 46

Thoracic aneurysms s/s

Back 46

Pain radiating to neck, shoulders, lower back, syncope, dyspnea, increased pulse, cyanosis, weakness, hoarseness, swelling difficulty

Front 47

Dx Test of Aneurysms in thoracic/abdominal

Back 47

Chest xray, ECG (Rule out MI), CT most accurate to determine the length and cross sectional diameter and presence of thrombus in aneurysm.

Front 48

Nursing Plan/Implementation of Aneursym in Thoracic/Abdominal

Back 48

Decrease risk factor (smoking cessation, decrease BP, control hyperlipidemia), annual monitoring of size, w/ CT, MRI, ultrasound. Notify physician if severe back/abd pain, fullness, soreness over umbilicus, sudden dev of discoloration in extremeties, or persistent elevation of BP. Aortic: Report SOB, cx/back pain, hoarseness or difficulty swalling

Front 49

Most severe complication of aneurysm

Back 49

Rupture. If thoracic or abd more then 90% die. Severe back pain will occur or severe abd pain, lumbar pain that radiates to flank/groin

Front 50

Surgical therapy for aneurysm

Back 50

Incising the diseased segment of aorta, removing thrombus/plaque, inserting a synthetic graft, or suture the native aortic wall around graft to act as a protective cover.

Front 51

Surgical repair of abd aortic aneurysm w/ a Woven Dacron graft

Back 51

Preop: assess all periphereal pulses as baseline for postop, instruct as cough/deep breathing exercises

Front 52

Postop surgical repair of abd aortic aneurysm w/ a Woven Dacron graft

Back 52

Monitor VS, airway, neuro assessment, encourage turning, coughing and deep breathing and splinting, monitor peripheral pulses distal to graft site, monitor for changes in pulse, cool to cold extremeties, severe pain, abd distention, monitor for hypovolemia, monitor urine output/BUN/Creatinine, assess bowel sounds, assess surgical site, instruct pt to avoid straining, medicate for pain, no smoking and avoid heavy lifting.

Front 53

Risk Factors for Phlebitis

Back 53

Mechanical irritation from catheter, infusion of irritating meds, and rarely infectious and usually resolves quickly after cath removal.

Front 54

What to do if edema is present in phlebitis?

Back 54

Elevate extremeity to promote reabsorption of fluid, apply warm/moist heat and NSAIDs.

Front 55

Venous thrombosis

Back 55

Formation of a thrombus in association w/ inflammation of the vein. Classifications of superficial vein thrombosis (SVT) and deep vein thrombosis (DVT)

Front 56

Etiology of Venous Thrombosis: Clue Three factors called Virchow's triad

Back 56

1: Venous statsis: age, a fib, obesity and immobility 2: Damage of the endothelium (inner lining of the vein: Surgery, causitive IV meds, fractures, hx of previous venous thromboembolism, IV drug abuse 3: Hypercoagulability of blood: genetics, high altitudes, hormone therapy, malignancies and tobacco

Front 57

Superficial Vein Thrombosis (SVT)

Back 57

Formation of a thrombus in a superficial vein

Front 58

S/S SVT

Back 58

Palpable firm subcutaneous cordlike vein. May be itchy, tender, or painful to touch, reddened, warm.

Front 59

Risk Factors SVT

Back 59

Age, pregnancy, obesity, malignancy, estrogen therapy, long distance travel

Front 60

Tx of SVT

Back 60

Low molecular weight heparin for 45 days, NSAIDs, compression stockings and mild exercise.

Front 61

DVT what is the preferred terminology?

Back 61

VTE

Front 62

Nursing Plan/Intervention for VTE

Back 62

Bedrest, elevate affected extremeity above the heart, avoid pillow under affected knee, do not massage, provide antiembolism stocking to reduce venous stasis, monitor for warmth and edema, measure/record circumference of thighs/calves, monitor for SOB and cx pain (can indicate PE, if so rapid O2 and notify physician), adminster heparin, monitor PT and INR, obtain medical alert, pt w/ lower VTE may or may/may not have unilateral s/s

Front 63

Drug therapy for VTE

Back 63

Anticoagulants.

Front 64

Three major classes of anticoagulants

Back 64

Indirect thrombin inhibitors, Vitamin K antagonist, and direct thrombin inhibitors

Front 65

Indirect Thrombin Inhibitors

Back 65

Heparin, Enoxaparin (Lovenox)

Front 66

Vitamin K Antagonists

Back 66

Warfarin (Coumadin)

Front 67

Drug Alert For Anticoagulant Therapy

Back 67

Avoid aspirin, NSAIDs, fish oil supplements, gingko biloba, and certain antibiotics (sulfamethoxazole and Bactrim). Instruct pt report signs of bleeding (black/bloody stools, bloody urine, coffee ground emesis, and nosebleeds), hypotension, tachycardia, ecchymosis

Front 68

Surgery for VTE

Back 68

Venous thrombectomy and placement of vena cava interruption device (Greenfield filter)

Front 69

Venous Thrombectomy

Back 69

Removal of thrombus through an incision in the vein, anticoagulation afterwards

Front 70

Vena cava interruption device

Back 70

can be inserted percutaneously through right femoral or right internal jugular vein. Filter device is opened and spokes penetrate vessel walls, filter acts as a sieve type device, permitting filtration of clots w/out interruption of blood flow. Filter may need removal/replacement overtime. Recommeneded if anticoagulation is contraindicated.

Front 71

Complications of Post Thrombotic Syndrome

Back 71

Chronic venous htn, stiff noncompliant vein walls and persistent venous obstruction. S/S pain, aching, heaviness, swelling, cramps, itching, and tingling.

Front 72

S/S of complications of PTS

Back 72

Persistent edema, increased pigmentation, eczema, secondary varicosities, lipodermtoscelrosis, skin on lower leg becomes scarred and the leg becomes tapered like an inverted bottle.

Front 73

Chronic Venous Insufficiency

Back 73

Condition that develops when leg veins/valves fail to keep blood moving forward can lead to venous leg ulcers. Not life threatening but painful, defibilitating and costly

Front 74

S/S of CVI

Back 74

Skin of lower leg appearing leathery, w/ char. brownish/brawny appearance, edema, eczema, and pruritus

Front 75

Common location for venous ulcers

Back 75

Medial malleolus. Wound irregularly shaped and tissue typically ruddy color. Ulcer drainage may be excessive. Pain is present and may be worse when leg is in dependent position.

Front 76

CVI Plan/Implementation

Back 76

Elastic or compression stockings, clean pair daily, avoid prolonged sitting/standing, constrictive clothing, and crossing legs, elevate legs 10-20 mins every few hours of the day, elevate legs aboe heart when in bed, cover open ulcers w/ dressings before applying compression stockings.

Front 77

Dilated vein

Back 77

Damaged/weakened walls w/ a leaky valve meaning they cannot close and open to control the blood flow in either direction

Front 78

S/S varicose veins

Back 78

Enlarged, raised veins, pain, cramps, aches, restless legs, itching/burning.

Front 79

CVI can progress to these symtpoms?

Back 79

Leg swelling/pain, discoloration and ulcers.

Front 80

Varicose Veins

Back 80

Dilated, tortuous subcutaneous veins most frequently found in the saphenous system

Front 81

Etiology of varicose veins

Back 81

Family hx, female gender, use of oral contraceptives, tobacco use

Front 82

S/S of varicose veins

Back 82

Heavy/achy feeling or pain after prolonged standing/sitting which is eleviated by walking/limb elevation, itchy/burning/tingling/throbbing/cramplike leg sensation, swelling restless or tired legs

Front 83

Care for varicose veins

Back 83

Rest w/ affected limb elevated, compression stocking, exercise such as walking

Front 84

Tx of varicose veins

Back 84

Sclerotherapy, laser/light therapy, and surgical procedures such as phlbectomy and vein ligation

Front 85

Sclerotherapy

Back 85

Injection of a substance that destroys superficial veins

Front 86

What is key factor to varicose veins?

Back 86

Prevention

Front 87

how to prevent varicose veins?

Back 87

Avoid sitting/standing for long periods of time, maintain ideal body weight, avoid wearing constrictive clothing and walk daily.