Arterial vs. Venous Disorders

• Understanding the differences between arterial and venous disorders is crucial for effective vascular issue management.

Arterial Occlusion vs. Venous Problems

• Arterial occlusion often presents with a cyanotic appearance due to a lack of oxygenated blood flow.
• Venous problems are characterized by dark pigmentation, often appearing dry and scaly, because of decreased venous circulation.

Venous Circulation and Edema

• Decreased venous circulation leads to edema because blood cannot efficiently return to the heart.
• Veins transport blood from tissues back to the heart, predominantly from the lower extremities.
• Edema forms when compromised venous circulation causes tissue fluid to pool in the extremities.
• Chronic venous insufficiency results in pigmentation changes, dry, scaly skin, and potential venous stasis ulcers.

Pain Characteristics

• Venous pain is described as an aching, cramping feeling, often relieved by activity or elevation of the extremity.
• Elevating an extremity aids gravity in blood flow return.
• Muscle contractions during activity squeeze veins, assisting blood return to the heart.

Arterial vs. Venous Disorders: Feature Comparison

• Arterial pain is sharp, cramping, and brought on by exercise.
• Venous pain is aching, cramping, and relieved by activity/elevation.
• Arterial pulses are diminished or absent.
• Venous pulses are usually present.
• Arterial edema is typically absent.
• Venous edema is typically present.
• Arterial skin is cold/cool, dry, shiny, and hairless.
• Arterial skin appears pale when elevated and erythematous when dangling.
• Venous skin is warm with darker pigmentation with possible stasis ulcers.

Arterial Disorders: Pain and Oxygen Demand

• Exercise induces arterial pain because muscles require oxygenated blood, impaired by arterial disease.
• Arteries deliver blood throughout the body from the heart.
• Arterial disease in the lower extremities causes pain during activity because of insufficient blood supply.

Venous Disorders: Relief with Activity

• Activity moves blood out of tissues and back into the venous system, alleviating venous pain.
• Exercise and physical activity improve venous return, reducing pooling in the extremities.

Pulses and Edema: Arterial vs. Venous

• Arterial pulses are diminished or absent due to blockage preventing blood flow.
• Venous pulses are usually present because the issue lies with blood return, not arterial supply.
• Arterial edema is typically absent because blood cannot reach the area.
• Venous edema is present because blood and fluid accumulate in the tissues.

Skin Changes in Arterial and Venous Disorders

• Arterial skin temperature is cooler due to decreased circulation.
• Arterial skin appearance is dry, shiny, and hairless due to poor circulation.
• Arterial skin color is pale when elevated, erythematous (red) when dangling.
• Venous skin temperature is warm due to blood pooling.
• Venous skin has a darker pigmentation with potential stasis ulcers.

Arterial Skin Color Changes

• Elevating the legs worsens arterial insufficiency, causing increased paleness.
• Raising the legs against gravity restricts blood flow further to the extremities.
• Dependent rubor (redness) occurs when dangling the legs due to blood pooling.

Venous Skin Temperature

• Extremities feel warm when there is blood pooling in the venous system.

Venous Stasis Ulcers

• Elevating the extremity reduces pressure and promotes venous return, treating stasis ulcers.
• Compression bandages, not hose, are used to encourage venous circulation over open wounds.
• An Unna boot includes a gauze bandage applied to promote venous return, hardening and staying on for one to two weeks.

Unna Boot Application

• Gauze is wrapped around the affected area to encourage venous circulation
• The Unna boot hardens and remains in place for approximately one to two weeks.

Venous Circulation Assistance & Wound Care: Unna Boot

• A specialized compression bandage, the Unna Boot, aids venous circulation, often extending from the ankle up to the calf.
• An Unna Boot assists with venous circulation and can be applied over a wound.

Wound Management

• Comprehensive care for wounds includes dressing changes, monitoring for potential surgical intervention and infection.
• Dressing changes are required every 1-2 weeks for some.
• Antibiotics are administered for signs and symptoms of infection.
• Surgical debridement may be necessary if conservative measures fail, particularly with necrotic tissue.

Nursing Interventions for Wound Care

• Focus is on wound management, monitoring dressing changes, and patient education.
• Monitor wounds regularly, change dressings as prescribed, assess for signs of infection and educate patients on preventative measures to enhance circulation.

Enhancing Circulation & Promoting Healing

• Strategies to improve circulation and support wound healing include lifestyle adjustments.
• Encourage physical activity and elevating the affected limb.
• A diet rich in protein is essential for promoting healing.
• Adequate rest is crucial for recovery.

Hypertension: An Overview

• Primary hypertension, also known as essential hypertension, constitutes 90-95% of hypertension cases and has no identifiable cause.
• Primary hypertension is often termed "essential hypertension" and has no known specific cause.
• Primary hypertension can be benign or malignant, and malignant hypertension is characterized by a diastolic pressure greater than 120 mmHg.
• Secondary hypertension results from an underlying, identifiable condition, and treating that condition can resolve it.

Risk Factors for Hypertension

• Non-modifiable risk factors are unchangeable factors influencing the likelihood of developing hypertension.
• Risk of hypertension increases with age.
• Men are generally at higher risk than women.
• African Americans have a higher prevalence of hypertension compared to Caucasians.
• A familial predisposition increases the risk of hypertension.
• Modifiable risk factors can be altered through lifestyle changes to reduce hypertension risk.
• Smoking causes vasoconstriction, increasing blood pressure.
• Obesity is associated with increased blood volume, leading to higher blood pressure.
• A high-sodium diet increases water retention and blood volume.
• Elevated serum cholesterol contributes to atherosclerosis and increases hypertension risk.
• Alcohol increases blood pressure.
• Emotional stress elevates blood pressure.
• A sedentary lifestyle increases the risk of hypertension.

Blood Pressure Classification

• Blood pressure classifications include normal, elevated, and stages of hypertension.
• Normal blood pressure is less than 120/80 mmHg.
• Elevated blood pressure is 120-129 mmHg systolic and less than 80 mmHg diastolic.
• Hypertension Stage 1 is 130-139 mmHg systolic or 80-89 mmHg diastolic.
• Hypertension Stage 2 is greater than 140 mmHg systolic or greater than 90 mmHg diastolic.
• Diagnosing hypertension requires multiple elevated readings
• Diagnosis necessitates two or more elevated blood pressure measurements taken at different instances
• A single elevated reading at the doctor's office is insufficient for diagnosis

Understanding Blood Pressure

• Systolic pressure reflects the force of the left ventricle's contraction.
• Diastolic pressure reflects pressure on arterial walls during the heart's relaxation phase.

Additional Risk Factors & Complications

• Other factors, like oral contraceptives, can contribute to hypertension, increasing the risk of high blood pressure.

Complications of Malignant Hypertension

• Severe consequences of uncontrolled high blood pressure emphasizes importance of management.
• High blood pressure damages small arterioles in major organs, including the heart, kidneys, brain, and eyes.

Common Causes of Death Related to Hypertension

• Major health issues—myocardial infarction, heart failure, stroke, renal failure & blindness—result from poorly managed hypertension.

Symptoms & Diagnosis of Hypertension

• Hypertension is often asymptomatic but advanced stages may present specific symptoms.
• Hypertension is often asymptomatic in early stages.
• Early morning occipital headaches upon waking, blurred vision, and nosebleeds may occur in more severe cases.

Diagnosis Criteria

• Diagnosing hypertension requires multiple readings as an average of two blood pressure readings on separate occasions.
• Systolic pressure greater than 140 mmHg or diastolic pressure greater than 90 mmHg.

Hypertension Management: A Comprehensive Guide

• Initial Assessment involves obtaining a complete history and physical and lab tests.
• Laboratory tests include a basic metabolic panel (BMP) with blood urea nitrogen (BUN), creatinine, electrolytes, complete blood count (CBC), fasting blood sugar, and lipid profile.
• An electrocardiogram (EKG) assesses heart function and detects ischemia or previous heart attacks.
• An echocardiogram assesses heart structure and function.
• A chest X-ray evaluates underlying lung or heart conditions.

Pharmacological Interventions for Stage 1 and 2 Hypertension

• Diuretics increase urine output, reducing blood volume and pressure.
• Beta blockers block the effects of adrenaline, slowing heart rate and reducing blood pressure.
• ACE inhibitors block the production of angiotensin II, a potent vasoconstrictor.
• Angiotensin II receptor blockers (ARBs) block the action of angiotensin II by preventing it from binding to its receptors.
• Calcium channel blockers relax blood vessels by preventing calcium from entering smooth muscle cells.
• Alpha agonists stimulate alpha-adrenergic receptors in the brain, reducing sympathetic outflow and lowering blood pressure.
• Direct Renin Inhibitor, Tekturna (Aliskiren), blocks renin, preventing it from raising blood pressure.

Lifestyle Modifications

• Weight loss; even modest weight loss can significantly lower blood pressure.
• Regular exercise 3-4 times per week for 30-45 minutes is recommended.
• Dietary changes include reducing saturated fat intake, consuming adequate potassium, calcium, and magnesium, limiting alcohol consumption, and reducing sodium intake.
• Smoking increases blood pressure and cardiovascular risk.
• Managing stress reduces stress levels by implementing relaxation techniques.

Accurate Blood Pressure Measurement

• During fundamentals, the patient should be seated with their arm supported at heart level, the appropriate size cuff applied to the bare arm, no coffee or smoking 30 minutes prior to measurement; the equipment should be calibrated.
• Initially, take measurements in both arms to establish a baseline.

Nursing Interventions

• Monitor blood pressure regularly, especially at the beginning of treatment.
• Assess blood pressure in both lying and standing positions to detect orthostatic hypotension.
• Administer prescribed medications as directed.
• Monitor for edema from some antihypertensive medications.
• Watch for signs and symptoms of blurred vision and/or orthostatic hypotension

Understanding Orthostatic Hypotension

• Antihypertensive medications can sometimes lower blood pressure too much, leading to hypotension
• Orthostatic hypotension is a common side effect of antihypertensive drugs.
• Hypotension is a well-known side effect of those medications.

Patient and Family Teaching

• Educate patients about their medications, including what to watch for.
• Reinforce importance of low-sodium diet and reduced saturated fat intake and encourage regular physical exercise.
• If applicable, emphasize the benefits of weight loss.
• Encourage patients to discuss sexual dysfunction with their provider, as alternative medications may be available.
• Abruptly stopping medication has risks of rebound hypertension.

Compliance with Antihypertensive Therapy

• Review measures to increase compliance with antihypertensive therapy.
• Patients tend to feel "cured" once regulated but must keep taking medications.
• Consequences of non-compliance include rebound hypertension, stroke, or other serious health issues.
• Review nursing interventions to reinforce understanding.

Factors Contributing to Non-Compliance

• Provide written instructions in layperson's terms, avoiding medical jargon.
• Address side effects like sexual dysfunction, which can be a major deterrent.
• Simplify dosing schedule.
• Educate patients regarding consequences of non-compliance.
• Explain that treatment is still necessary given hypertension is often asymptomatic.

Hypertensive Crisis

• A life-threatening condition requiring immediate attention.
• Treatment typically involves IV medications, administered most often by an RN.
• Precipitating factors include abrupt withdrawal from antihypertensive medications, pheochromocytoma, stroke & acute myocardial infarction (MI).

Arterial Aneurysms

• A distended, weakened bulge in the arterial wall is considered an arterial aneurysm.
• Common sites are the thoracic and abdominal aorta (most common), and popliteal and femoral arteries.
• Three-fourths of aortic aneurysms occur in the abdomen.
• Plaque buildup can contribute to aneurysm formation.

Aneurysms

• Most common causes of aneurysms aren't explicitly stated but smoking and hypertension are significant contributing factors.
• Increased pressure in blood vessels and age increases risks.
• Thoracic aneurysms are often asymptomatic initially, and symptoms can include chest pain and hoarseness.
• Other symptoms include difficulty swallowing, distended neck veins due to pressure on vena cava, etc.
• Abdominal aneurysms are initially asymptomatic.
• Chest pain, back pain (common in men), possible scrotal pain, and a pulsating non-tender mass may occur in the upper abdomen and/or a bruit on auscultation may be evident.
• Ruptured aneurysms are life-threatening.
• Symptoms include severe back pain, bluish discoloration on the side/back, shock including a pale, weak, tachycardic, low blood pressure and acute onset chest and abdominal pain.
• Treatment can be surgical via graft or synthetic fiber to replace the vessel.
• Non-surgically, blood pressure control as a top priority, involves medications like beta blockers

Raynaud's Phenomenon

• Raynaud's phenomenon includes episodic vasospasms of small skin arteries primarily in fingers.
• The etiology is unknown, but is more common in women, and prevalent in winter months.
• It mainly affects fingers but can also affect toes, ears, and nose.
• Triggers include cold and emotional stress.
• Chronically cold hands and feet are indicative of reactive hyperemia.
• During arterial spasms, pallor, coldness, numbness, cutaneous cyanosis, burning, throbbing, edema, and blanching occur.
• Chronic cases may result in ulcerations of fingers and toes.
• Calcium channel blockers such as nifedipine and stress management are preferred options of treatment.
• Advanced cases with ulcerations and gangrene may require amputation
• Educate patients to keep extremities warm, avoid temperature extremes & contact with cold objects, avoid amphetamines, cocaine, and smoking; to limit caffeine intake, and brief warm water soaks provide vasospasm relief.

Varicosities (Varicose Veins)

• Varicosities, or varicose veins, are weakened and dilated veins with incompetent valves, leading to blood pooling.
• Risk factors include obesity, pregnancy, tight clothing, prolonged standing, and family history
• Valves in veins become incompetent, leading to blood pooling due to dilation and are more common in women.
• Factors worsening varicosities: overexposure to sun (dilates blood vessels), hot tubs, tight clothing, high-heeled shoes, lack of exercise, prolonged sitting or standing.
• Visible, tortuous veins and feelings of heaviness or pressure indicates varicosities
• Changes includes skin thickening, pigmentation and color and edema.
• Cramp-like pain at night and after prolonged standing or menstrual pains also are symptoms
• Diagnosing varicosities include Doppler ultrasound, venogram & Trendelenburg tests
• Treatment includes compression stockings, rest, leg elevation, sclerotherapy, laser surgeries, venous stripping and ligation
• Watch for distal pulses and/or bleeding
• Instruct patient NOT to gatch surgical knee

Post-Operative Knee Considerations & Venous Return

• Following knee surgery, specific post-operative care to ensure proper healing and prevent complications is important.
• This post-operative care includes optimizing venous return, monitoring circulation, and preventing thrombophlebitis.
• Knee positioning can negatively impact surgery outcomes.
• Improper positioning can cause pooling of fluids, further complicating recovery
• Elevating the foot of the bed enhances return as well, which improves healthy circulation and decreases chance of complications.

Varicose Veins and Interventions

• Varicose veins and related conditions require specific management strategies to alleviate symptoms and prevent complications.
• A UNA boot aids other venous insufficiency scenarios.
• Avoid restrictive clothing.
• Make lifestyle modifications by not crossing legs, limiting prolonged sitting, and maintaining regular exercise and weight.
• Avoid sitting in chairs that are too high /wearing garters or knee-high stockings.
• Legs should be elevated to promote their return

Thrombophlebitis: Inflammation and Thrombosis

• Inflammation includes a vein with thrombus (clot) formation.
• Types include superficial thrombophlebitis and deep vein thrombosis (DVT).
• Recognize pain/edema and increase in calf(or affected leg area) circumference and other leg in legs.
• Look for erythema and warm skin, also can be caused by vein being palpated/touched around it from tenderness
• Homan's sign isn't a helpful (unreliable) method.

Risk Factors for Thrombophlebitis

• Increased risk due to factors like vessel damage and/or clotting disorders like sickle cell anemia or polycythemia vera
• Venous stasis, immobility (surgery), sedentary lifestyle and/or dehydration
• Also due to cancer, obesity and birth control pills increase the thrombus creation

Diagnostic Tests for Thrombophlebitis

• Use a Venous Doppler/Duplex Scan to visualize blood flow.
• Use a Venography (of veins) to inject contrast dye.
• An elevated D-dimer suggests a clot is present somewhere in the body.

Treatment for Thrombophlebitis

• Treatments vary based on whether the thrombophlebitis is superficial or a DVT.
• Superficial Thrombophlebitis includes elevation of affected limb as well as anti-inflammatory medications, and warm compresses.
• DVT includes anticoagulants, warm compresses, bed rest, leg elevation, compression stockings, and surgery.

Prevention of DVT

• Early ambulation as much as possible and/or during bed rest in surgery.
• Leg range of motion and/or elevation.
• Stockings or compression boots or pneumatic compression devices.
• Fluid intake and in high-risk patient’s low-dose Anticoagulant Therapy.
• Warfarin (Coumadin)
• Target is for Therapeutic INR range of 2-3. Elevated beyond "3" and low anticoagulation numbers of "2", increased bleeding & blood not therapeutic enough.
• Transvenous placement includes placement of a filter of grid.

Nursing Interventions for Thrombophlebitis

Positions patients can do and use includes feet ankles to promote and aid venous flow.

• Early ambulation and frequent position changes if bed ridden
• Elastic compression stockings
• Prolonged inactivity, so avoid long periods of sitting and standing as much.
• Precautions include to avoid no massaging extremities for it can move clots and increase risk of a situation.
• Wear travel stockings and/or ambulate during travel.
• For acute/immediate issues should include the following: follow provider's guidance, elevate extremity to reduce edema and monitor and medications.
• Measuring edema involves to follow guidelines to ensure consistent results, and consistent place to check to accurately monitor, and mark area to check accurately over time.