Arteries and Veins: Vascular Health

Blood Vessels: Arteries

• Arteries carry blood to vital organs and tissues.
• They are responsible for perfusion, offering nutrients to tissues.
• Perfusion signs include pink, warm skin, palpable pulse, and brisk capillary refill.
• Approximately 30% of blood in systemic circulation is found in the arteries.

Blood Vessels: Veins

• Veins carry blood back to the heart and lungs.
• They remove waste products.
• They collect fluid from the lymph system.
• About 65% of blood in systemic circulation is found in the veins.

Arterial Vascular Disease

• Arterial vascular disease includes arteriosclerosis and atherosclerosis.
• Arteriosclerosis involves the hardening of the arterial wall and can originate from any source.
• Atherosclerosis is a type of arteriosclerosis where plaque forms in or on the arterial wall.

Arteriosclerosis Risk Factors:

• Age is a risk factor for arteriosclerosis.
• Smoking causes vasoconstriction, hypertension, endothelial cell and platelet dysfunction, and increased cholesterol.

Atherosclerosis Risk Factors:

• Low HDL, high LDL, and triglycerides are risk factors.
• Additional factors include hypertension, genetics, diabetes, obesity, sedentary lifestyle, smoking, and stress.
• African or Hispanic ethnicity and older adults are also at increased risk.
• Managing BP, glucose, and cessation of smoking are recommended.

Hypertension (HTN)

• Hypertension occurs when there is an increase in either cardiac output (CO) or peripheral vascular resistance (PVR).
• In younger individuals, increased CO is more frequently the cause.
• In older populations, increased PVR is more commonly the cause.
• Hypertension stages include:
  • Normal: 120/80
  • Prehypertension: 120-139/80-89
  • Stage 1 HTN: 140-159/90-99
  • Stage 2 HTN: >160/100

Primary/Essential HTN

• Primary or essential hypertension isn't caused by other diseases.
• Risks include family history, smoking, obesity, diabetes, salt sensitivity, and renin elevation.

Secondary HTN

• Secondary hypertension is secondary to other diseases.
• For example: kidney disease, obesity, alcoholism, Cushing's disease, and hyperthyroidism, or stimulant use.
• Hypertensive crisis, defined as >180/120, can lead to heart failure, acute kidney injury, and cerebrovascular accident (CVA).

Causes of Hypertension

• Increased sodium intake.
• Renin-angiotensin-aldosterone system (RAAS).
• Elevated aldosterone.
• Sympathetic nervous system activity.

Antihypertensive Medications

• Diuretics.
• Calcium channel blockers (CCBs).
• ACE inhibitors (ACE-Is).
• Angiotensin II receptor blockers (ARBs).
• Beta-blockers.
• Combined Alpha and Beta blockers.
• Vasodilators.
• Central agonists.

Complications of Hypertension

• Known as the “Silent Killer,” hypertension can damage the brain, heart, and kidneys without obvious symptoms.
• Can lead to atherosclerotic cardiovascular disease (ASCVD)/heart failure, CVA, aneurysm, aortic dissection, and hypertensive crisis.

Pediatric Hypertension

• Symptoms include waking up screaming in pain, banging head against a wall, irritability, and tension.
• Children may not be able to verbalize discomfort.
• They are more likely to have secondary hypertension until adolescence.
• Often related to kidney disease, congenital heart defects, endocrine disorders, or medications.
• Essential hypertension in children is usually only mildly elevated.
• Treatment includes diet and salt restriction, exercise, and stress reduction.
• If medication is necessary, diuretics, beta-blockers, CCBs, ACE-I, and ARBs may be prescribed.

Peripheral Arterial Disease (PAD)

• PAD is a chronic problem related to atherosclerosis.
• Risk factors are the same as for ASCVD.
• The amount of activity required to cause pain decreases as the disease progresses.
• Leg pain often occurs at night, waking individuals from sleep.

Peripheral Arterial Disease Stages

• Stage I: Asymptomatic - the patient has no claudication.
  • A bruit or aneurysm may be present.
  • Pedal pulses may be decreased or absent.
• Stage II: Claudication - muscle pain, cramping, or burning occurs with exercise and is relieved with rest; symptoms are reproducible with exercise.
• Stage III: Rest Pain - pain while resting commonly awakens the client at night, described as numbness, burning, or toothache-type pain.
  • It usually occurs in the distal portion of the extremity.
  • This can be relieved by placing the extremity in a dependent position.
• Stage IV: Necrosis/Gangrene - ulcers and blackened tissue.
  • These occur on the toes, the forefoot, and the heel.
  • A distinctive gangrenous odor is present.

Lower Extremity Ulcers:

• Arterial and venous ulcers are a common vascular disorder
• The main differences in venous and arterial diseases are:
  • location of wounds
  • appearance of wounds
  • symptoms of the disease
  • treatments

Critical Limb Ischemia

• Lower extremity can be assessed according to the feature, history, and diagnosis
• In severe cases there may possible gangrene, neurologic deficits and no pulses

Nursing Care of Arterial Vascular Disease

• Assess the patient's legs for hair loss, poor or absent pulses, redness when dependent, pale when elevated, and necrotic ulcers on the toes with dry wound beds.
• Diagnose: Ineffective peripheral tissue perfusion, risk for impaired skin integrity, and chronic pain.
• Implement: Monitor for signs of bleeding, position the legs in a dependent position, inspect the feet daily, and educate on risks, claudication, and the importance of wearing shoes to prevent injuries
• Educate: educate on medications prescribed

Acute Limb Limbischemia

• Acute limb ischemia (ALI) include:
  • Pain
  • Pallor
  • Pulselessness
  • Paresthesia
  • Paralysis
  • Poikilothermia (coolness)

Carotid Artery Disease

• Refers to stenosis or narrowing of the carotid arteries, which supply blood to the brain.
• Stenosis is classified as:
  • Mild (<50% narrowing).
  • Moderate (50-69% narrowing).
  • Severe (70-99% narrowing).

Aortic Artery Disease (Aneurysms)

• Can occur at any point on any artery.
• Aneurysms are most common in the abdominal aorta (AAA) and thoracic aorta (TAA).
• Risk factors are the same as for peripheral artery disease, along with genetics, Marfan syndrome, syphilis, bicuspid aortic valve, and Kawasaki disease.
• Aneurysms are diagnosed via CT with contrast.
• Controlling hypertension is crucial to avoid rupture.

Aortic Dissection (Dissecting Aneurysm)

• Involves a sudden tear in the intima, leading to a false lumen.
• This grows rapidly under pressure, causing loss of distal circulation and potential rupture with internal hemorrhage.
• Paitents will experience tearing, ripping back pain.

Surgical Repair

• Post-operative care includes continuous vascular monitoring and assessment.
• Post surgical repair patients are at a high risk of occlusion in the first 2 weeks
• You should always check circulation, sensory, motor functions, pulses and be on alert of bleeding

Other Arterial Health Problems

• Buerger's Disease
  • Night leg Pain from claudication. r/t smoking
• Raynaud’s Phenomenon
  • Painful vasospasms in extremities
• Subclavian Steal
  • Arm pain from obstruciton of subclavian flow
• Thoracic Outlet Syndrome
  • Positional comrpession of hte subclavial artery

Peripheral Venous Disease:

• Accumulatoin of fluid and waste
• Superficial thrombophlebitis, localized warmth and tenderness, and VTE

VTE- Venous Thromboembolism

• Clot in vein due to endothelial injury, venous stasis, hypercoagulability (virchow's triad)
• Assessrisk factors, implement prevention measures, watch for s/s
• Swelling will be present distal to the clot

VTE Diagnostic Tests

• D-dimer
• Pt/ aPTT/ INR
• H/H
• Ultrasound
• CTA to asses for PE

Venous Insufficiency

• Stasis dermatitis, stasis ulcers, edema, brown legs

Varicose Veins

• Due to venous valvular insufficiency from chronic backpressure (prolonged standing, obesity)

Cellular Hypoxia in Shock

• Any problem impairing oxygen delivery to tissues and organs can precipitate shock.
• This leads to widespread abnormal cellular metabolism, where oxygenation and tissue perfusion are not adequately met.
• The body has a "whole-body" response, which can lead to a life-threatening emergency.

Regulation of Blood Pressure:

• BP: Cardiac output X PVR
• CO: HR X SV
• MAP: 2/3diastole + 1/3systole
• Preload & afterload

Classification of Shock Causes:

• Hypovolemic/hemorrhagic -loss of volume -low preloada, low SV, low CO, low MAP
• Cardiogenic -Pump failure -low SV, low co, low MAP
• Distributive -dilated container and leaky capillaries -low preload, low SV, low CO, Low MAP
• Obstructive -decreased preload or increased afterload -low SV, low CO, low MAP
• All of these lead to a mismatch of oxygen supply and demand

Clinical Manifestations of Shock by Stage

• Initial
  • no manifestations
• Non-progressive
  • vasoconstriction -increased PVR -increased glycogenolysis
• progressive -increase shunting -failure of NA, K pump
• refractory -systemic anaerobic metabolism

Response to Progression of Shock

• Sympathetic nervous system releases: EPI, Norepi re-establisihing heart rate, force and blood flow

Renin Response to Progression of Shock

• RAS is activated & vasoconstricts to stimulate ADH and Aldosterone

Antidiuretic Hormone

• posterior pituitary senses hypovolemia, increasing water and sodium absorption in kidneys

Intercellular fluid shift

• the goal is to maintain volume by moving intercellular volume by to instravscular volume

Responses to Progressive shock

• Altere capillary permeability: fluid in protien leak, pulmonary edema and impaired gas exchange

Cardiac depression

• decreased:preload, SV, CO, BP/MAP
• Tissue:organ ischmeia
• Neuro decreasded: cerebral flow and AS

Nursing Prioritization of Care for Shock

Airway

• Ensure airway is secure Breathing
• Provide Oxygen/ Ventilator if needed Circulation
• Access circulation & Volume of BP Reason
• Determine the cause of shock Vitals
• Vitals should be observed & watch and MAP Urine
• Output should be monitored Skin
• Should be assesed Monitor
• Monitor CNS for adequate perfusion Treat
• Treat with medications

Additional Monitoring for Pt in Shock

• Ineffective peripheral tissue perfusion, risk for impaired skin integrity, and chronic pain monitor by doing: -arterial lines -pulmonary artery central venous catheter -ABGs monitor base excessive -CBC monitor potassium/ Lactic Acid

Hypovolemic Shock

• loss of fluid leads decrease fluid compartments and can be corrected by: -rehydrating -correcting the loss of volume -monitor H/H

Cardiogenic Shock

• Results in Left ventricular pump failure caused by: MI, Cardiomyopathy, Cardiac Arrest
• corrected by: Volume to be administered Gently Carefully monitor I/O daily weights electrolytes

Obstructive Shock

• Caused and treated by: Treating the underlying problem Percardiocentesis chest compression Thrombectomy

Distributive/ Neurogenic Shock

• Caused by: Loss of sympathetic tones and 3rd spacing CNS/cord injuries and insult to vasomotor center
• Treatment: treating underlying problem and administrating medication Cautious to fluids and increase BP

Anaphylactic Shock

• Can be treated be finding the cause
• Removal of the agent causing it
• Administration of epinephrine, fluids, oxygen or Antihistamines/ steroids

Sepsis and SIRS

• If local infection gets into the system it can cause infection in the system and cause organ failure leading to MODS and death if left untreated.

Shock: Sepsis/Septic

Leading to shock has:

• Pulmonary infections
• Infections from Catheters and Stasis
• Skin loss of integrity And can be prevented by:
• Sterilizing equipments
• Wash hands - Keep skin intact

Distributive- SEPSIS/SEPTIC Shock:

• Can be treated by:
• Decreasing PVR, Preload, Stroke volume, CO and BP
• Managed with treatment that consist of pulmonary,urinary,skin and administer antibiotics.

Multiple Organ Dysfunction:

• Can occur by:
  • Disrupting cells through the body system releasing toxi metabolites and enzymes along
  • A progressive chain of events occurs such as: -ARDS/KI/LI Failure leading to GI Failure Which results in a 100% mortality rate and leads to permanent failure.

Drug Theropy:

• can be used by:
• Dopamine/Epinephrine/Norepinephrine
• Agents Enhancing Contractility
• Agents Enhancing Myocardial Dopamine Nitroglycerin

Pediatric Management for Shock

• In pediatric setting the common causes includes:
  • Trauma, Dehydration, Blood Loss

Always watch the patient

• Restfulness
• Effortless Tachypnea
• Tachycardia
• pallor
• Decreased UOP

The goal of the treatment is to:

• Ventilatory Support and medication assistance
• Airwave Breathing OXYGEN AbGs
• Cardiovascular Support
• fluid bolusing * correct labs