Abdominal Aortic Aneurysm (AAA), Deep Vein Thrombosis (DVT), Peripheral Arterial Disease (PAD) Quiz

Abdominal Aortic Aneurysm

• An aneurysm is a local dilation of an artery.
• Abdominal aortic aneurysm (AAA) is particularly concerning.
• Dissection or rupture of an AAA is life-threatening.
• Atherosclerosis is a common cause that weakens blood vessels.

Types of Aneurysms

• True aneurysms include fusiform and saccular types.
• Dissecting aneurysms are also a type of true aneurysm.
• False aneurysms exist as well.

Signs and Symptoms of AAA

• Often, there are no symptoms.
• Pain may occur in the chest, abdomen, or flank.
• Awareness of a pulsating mass in the mid-abdomen may be present.
• Some patients experience back pain.
• Sudden, severe back or abdominal pain indicates dissection or rupture, requiring emergency intervention.

Risk Factors for AAA

• Atherosclerosis
• Hypertension (HTN)
• Smoking
• Obesity
• Family history
• Male gender
• Age greater than 65 years

Diagnosis of AAA

• Ultrasound
• Abdominal X-ray
• CT scan and MRI
• Angiogram before surgery

Medical Management of AAA

• Monitor the size of the aneurysm through surveillance.
• Control hypertension.
• Prevent, control, and treat atherosclerosis.
• Smoking cessation

Surgical Management of AAA

• Surgery if the aneurysm is greater than 4-5 cm, growing rapidly, or producing symptoms.
• Ruptured AAA requires immediate surgery.

Post-Operative Nursing Care

• Assessment
• Address patient problems and nursing diagnoses
• Interventions
• Evaluation and patient education

Nursing Diagnosis & Interventions for Endovascular Aortic Repair

• Check the groin site, pulses, and blood pressure.
• Ensure the patient is hemodynamically stable.

Nursing Diagnosis & Interventions for Open Repair

• Risk for ineffective tissue perfusion
• Monitor urine output, targeting 30 ml/hr, assessing BUN and creatinine.
• Blood pressure management is important, avoiding excessive pressure on the graft.
• If systolic BP is too low (systolic > 100) assess distal perfusion.
• Manage pain and administer IV fluids or vasoactive drugs as needed.

Post-Operative Nursing Interventions

• Monitor distal pulses for lower extremity perfusion, watching for graft thrombosis or occlusion.
• Bowel ischemia risk can occur due to aorta clamping, leading to paralytic ileus.
• Assess bowel sounds and abdominal distention, maintaining NG until flatus is present.

Risk for Fluid Volume Deficit

• Monitor vital signs and hemodynamic variables, and administer IV fluids as prescribed.
• Monitor dressings for drainage.
• Assess for abdominal or back pain.
• Monitor hemoglobin, hematocrit, and electrolytes for signs of hemorrhage.

Post-operative Nursing Diagnoses

• Risk for infection
• Monitor vital signs, WBCs, and wound status, and administer antibiotics as ordered.
• Manage pain, potentially with PCA.
• Risk for ineffective tissue perfusion
• Risk for bleeding
• Risk for fluid volume deficit

Post-operative Goals

• Adequate tissue perfusion
• Adequate renal and bowel function
• Adequate fluid balance
• Adequate pain control

Overview of Deep Vein Thrombosis

• Deep vein thrombosis (DVT) involves blood clot formation in deep veins, typically in the legs, but can occur in the arms and neck (rare).
• A major complication of DVT is pulmonary embolization.

Pathophysiology of DVT

• Three conditions of Virchow's triad: venous stasis, hypercoagulability of blood, injury to venous wall.

Clinical Manifestations of DVT

• Symptoms may be absent.
• Edema, warmth, and redness can occur.
• Calf pain or thigh tenderness, and aching pain are common.
• Increased temperature and WBC counts may be present.

Risk Factors for DVT

• Inherited clotting disorders like Factor V Leiden deficiency
• Prolonged bedrest or sitting, causing venous stasis
• Smoking
• Oral contraceptives (hypercoagulability)
• Injury or surgery.
• Pregnancy

Prevention of DVT

• Lifestyle modifications: weight loss, exercise, smoking cessation and fluid intake
• Core measure: Venous thromboembolism (VTE) prophylaxis
• Promote tissue perfusion and prevent venous stasis
• Wear compression stockings
• Avoid clothes that constrict the legs
• Avoid prolonged sitting or standing
• Encourage exercises and physical activity
• Passive ROM
• Maintain desired weight for height
• Identify at risk populations: immobility, post operative, surgical patients older than 40, Heart diseases who undergo major abdominal surgery, pelvic, or orthopedic surgery

Prevention of DVT: Medications

• Administer prescribed anticoagulants such as SQ heparin, Lovenox (enoxaparin), or Xarelto (rivaroxaban).

Medical Management for DVT

• Diagnostic tests: Venous duplex scan, venogram, D-dimer.
• Diet: Increase fluid intake and dietary fiber, and monitor Vitamin K intake if on Coumadin.
• Activity: promote venous blood flow, helps maintain muscle tone and joint mobility, and increase sense of well-being
• Anticoagulation

Anticoagulation Medications

• Heparin: Given SQ or IV; monitor aPTT (50-75 = goal), delays clotting time and prevents new thrombus formation.
• Enoxaparin (Lovenox): Given SQ as prophylaxis.
• Warfarin (Coumadin): Given PO; monitor PT/INR; used to "bridge" to warfarin.

Surgical Management for DVT

• Thrombectomy: Rarely performed; removal of thrombus only if anticoagulant therapy is contraindicated.
• IVC Filter (Greenfield filter): Placed in the inferior vena cava to trap large emboli and prevent pulmonary embolism.

DVT Assessment

• Subjective: pain in calf at rest or with exercise; tenderness; history of DVT.
• Objective: unilateral ankle edema; rapid swelling of limb; redness; warmth; increase in skin temperature; low-grade fever.

Nursing Diagnosis & Actions for DVT

• Ineffective Tissue Perfusion: compression stockings, check pulses, monitor calf circumference, anticoagulant therapy, teach patient to avoid standing, monitor for pulmonary edema.
• Pain: warm packs, analgesics. Avoid ASA if on anticoagulants, suggest Tylenol

Nursing Diagnosis & Actions for Ineffective Health Maintenance

• Take oral anticoagulant same time everyday, do not stop unless MD discontinues order.
• Labs usually 1-2 weeks after discharge.
• Monitor intake of dark greens.
• Restrict alcohol intake as it can increase anticoagulation effect.

DVT Core Measures

• DVT occurs in 10-40% of hospitalized patients who do not receive prophylaxis, with a higher incidence in those with risk factors.
• Pulmonary embolism is a fatal complication, accountable for 10% of in-hospital deaths.
• Pharmacologic prophylaxis can reduce the risk of developing a DVT by 40-60%.
• Compression devices may be used in those with contraindications to pharmacologic prophylaxis.

Chronic Venous Insufficiency (CVI)

• Blood flow through the veins is inadequate, causing blood pooling in the legs
• Causes of CVI

Causes of CVI

• Malfunction of venous walls and/or valves in systemic circulation.
• Varicose veins—incompetent valves
• Blood clots—obstruction of the veins
• Obesity, fluid retention, inactivity

Assessment Findings of CVI

• Thin, shiny skin
• Weeping dermatitis
• Leg aching
• Brown skin pigmentation

Post Thrombotic Syndrome

• CVI can be a complication of DVT
• Pain
• Swelling
• Skin ulcers

Treatment for CVI

• Common interventions for CVI
• Leg elevation
• Compression stockings
• Avoid standing for long periods
• Prevent crossing legs
• Prevent constrictive clothing

Treatment of CVI

• Compression stockings improve circulation by squeezing muscles and vessels.
• Medications: diuretics, anticoagulants, increase blood flow.
• Surgery: vein bypass.

Overview of Peripheral Arterial Disease

– Segmental narrowing within the intima (inner layer of artery).

• Affects large arteries of the lower extremities.
• Common sites include the femoral, iliac, and popliteal arteries; the aorta is also affected.
• Arteriosclerosis/Atherosclerosis is the main cause
• PAD is more prevalent in men, usually ages 60-80 years

Pathophysiology of PAD

• Atheromatous plaque formation narrows arteries leading to chronic ischemia and decreased blood flow Calcification of the media layer and loss of elasticity
• Inadequate blood supply to tissues, tissue hypoxia.

Clinical Manifestations of PAD

• Intermittent claudication/pain: cramping/aching relieved by rest.
• Rest ischemia/pain: severe pain at night, often in feet and toes, relieved by dependency.
• Extremities pale/reddish
• Absent hair
• Unhealing foot ulcers
• Decreased or absent pulse

PAD vs CVI Comparison

PAD

• Pallor when elevated.
• Rubor when dependent​.
• Skin: Cool
• Edema: Absent or mild.
• Gangrene: May occur.
• Pulses: Decreased or absent

CVI

• Brown pigmentation, stasis dermatitis.
• Skin: warm
• Edema: May be significant
• Gangrene: Does not occur.
• Pulses: Normal

The 6 P's of Peripheral Vascular Assessment

• Pain
• Pallor
• Paresthesias
• Pulselessness
• Paralysis
• Poikilothermia

Risk Factors & Prevention for PAD

• Smoking cessation is critical
• Manage hypertension
• Reduce hyperlipidemia
• Blood Sugars less than 100
• Maintain activity

Risk Factors

• Family History/Poor vascular heredity
• Diabetes/ affects atherosclerotic processes and accelerates process
• Age

Medical Management of PAD

• Exercise and intermittent claudication
• Diagnostic Tests: Doppler ultrasound/duplex imaging, ABI

Medical Management Medications

• Blood viscosity reducing agents Decreases blood viscosity and increase blood flow Example: Pentoxifylline
• Antiplatelet drugs/Aspirin Clopidogrel (Plavix) Cilostazol – also relieves symptoms of intermittent claudication

Surgical Management of PAD

• Arterial bypass graft
• Endarterectomy
• Angioplasty: PTA - Percutaneous Translumenal Angioplasty and LABA - Laser Assisted Balloon Angioplasty
• Peripheral atherectomy
• Amputation as a last resort

Post Operative Nursing Care for PAD

• Assess peripheral pulses.
• Pulse checks, temperature/color, capillary refill
• Notify MD if no pulse or if limb threatened
• Assess for bleeding, hematoma, or swelling
• Bedrest evening with leg flat; then leg elevated
• Prevent leg crossing and administer antibiotics.

Nursing Interventions

• Proper positioning
• Promote comfort
• Skin and foot care
• Promote activity and mobility
• provide teaching

Nursing Diagnosis for PAD

• Ineffective Tissue Perfusion: Peripheral
• Impaired Skin Integrity (or Risk for)
• Pain, Chronic Pain
• Activity Intolerance
• Ineffective Health Self -Management

Evaluation for PAD

• Complies with protecting extremities.
• No pain, increased activity tolerance.
• Intact tissue integrity and decreased edema.
• Adheres to foot care regimen.