Untitled Quiz

Assessment and Management of Patients

• This chapter (32) in the 4th edition of a medical-surgical nursing textbook covers the assessment and management of patients with vascular disorders and peripheral circulation problems.
• The chapter discusses the vascular system, including arteries, arterioles, capillaries, veins, venules, and lymphatic vessels.
• It also includes the function of the vascular system, systemic and pulmonary circulation (with a figure), peripheral blood flow, flow rate calculations, and various assessment characteristics.

Vascular System Components

• Arteries and arterioles
• Capillaries
• Veins and venules
• Lymphatic vessels

Systemic and Pulmonary Circulation

• This figure shows the systemic and pulmonary circulation pathways.
• Key components of the circulatory system are labeled, including the superior vena cava, right pulmonary veins, pulmonary circulation, pulmonary artery, left pulmonary veins, left atrium, left ventricle, aorta, left atrium, superior and inferior vena cava, hepatic circulation, and renal circulation. Crucially, it demonstrates the connections between these components, illustrating the flow of blood through the pulmonary and systemic circuits.

Peripheral Blood Flow

• Flow rate is determined by the formula ΔP/R (pressure difference divided by resistance).
• Factors affecting blood flow include blood viscosity and vessel diameter.

Assessment

• Characteristics of arterial and venous insufficiency are discussed with reference to a table identified as table 32-1.
• Intermittent claudication, rest pain, skin and appearance changes, pulses, and aging changes are assessed. Crucial aspects of the assessment are highlighted, including patient complaints and observable signs of vascular insufficiency.

Intermittent Claudication

• It involves muscular, cramp-like pain in the extremities consistently related to exercise/activity.
• The pain is relieved by rest.
• A half-obstructed lumen (50%) is a critical point in which intermittent claudication may arise.

Rest Pain

• Persistent pain in the feet or fingers when resting.
• A strong indicator of severe arterial insufficiency.
• Can lead to possible clots/ulcers.

Changes in Skin and Appearance

• Inadequate blood flow causes cool/pale extremities.
• Other signs include hair loss, brittle nails, dry/scaling skin, and ulcerations.

Pulses

• Assessing the presence, absence, and quality of pulses provides valuable information about arterial blood flow.
• This is a critical step in the assessment and diagnosis of arterial insufficiency issues.

Aging Changes

• In older adults, PAD symptoms are often more severe.
• In older inactive adults, gangrene may be the initial sign of PAD.

Assessing Peripheral Pulses

• The chapter describes methods of assessing peripheral pulses, using figures(Fig 32-2).
• The assessment emphasizes techniques to assess pulse quality, which includes appropriate pressure application techniques.

Continuous-Wave Doppler Ultrasound

• A technology for assessing the speed or volume of blood flow.

Question 1

• 50% of the arterial lumen must be obstructed to trigger intermittent claudication.

Diagnosis of Peripheral Vascular Disease

• Ankle-brachial index (ABI) is used.
• Calculations involve comparing the systolic blood pressure at the ankle with the systolic blood pressure in the upper arm (using the same arm), highlighting a crucial step in evaluating the presence of PAD.

Atherosclerosis and Arteriosclerosis

• Atherosclerosis – An inflammatory process involving the accumulation of lipids, calcium, blood components, and fibrous tissue within the artery's lining (intima).
• Arteriosclerosis- A diffuse process causing thickening of the muscle fibres and endothelial lining of the walls of small arteries and arterioles.
• Atherosclerosis can be linked to age-related wear and tear in arteries, whereas the disease itself can be potentially avoided.

Risk Factors

• Tobacco use
• Diet
• Hyperlipidemia (high blood lipids)
• Diabetes
• Stress
• Sedentary lifestyle
• Age
• Gender
• Genetics

Prevention

• Decrease lipids and cholesterol levels
• Increased exercise

Clinical Manifestations

• Coronary artery disease
• Cerebrovascular disease (stroke)

Medical/Surgical Management

• Risk modification (changes in lifestyle)
• Exercise
• Pharmacotherapy (medications)
• Angioplasty
• Stenting
• Coronary artery bypass grafting (CABG)

Progression of Atherosclerosis

• This figure demonstrates the stages of atherosclerosis progression over time, from fatty streaks to complicated lesions, and to potential complications such as myocardial infarction or stroke, highlighting the disease's severity and progression.

Common Sites of Atherosclerotic Obstruction

• A figure is provided illustrating the common locations of atherosclerotic blockages throughout the arterial system. Crucial aspects of the arterial tree that can be significantly impacted are shown.

Nursing Process: Assessment

• Health history
• Medications
• Risk factors
• Signs & symptoms of arterial insufficiency
• Claudication and rest pain
• Color changes
• Weak or absent pulses.
• Skin changes

Nursing Process: Diagnosis

• Altered peripheral tissue perfusion
• Chronic pain
• Risk for impaired skin integrity
• Knowledge deficiency

Nursing Process: Planning

• Increase arterial blood supply
• Promote vasodilation
• Prevent vascular compression
• Relieve pain
• Maintain/achieve tissue integrity
• Adherence to self-care programs

Improving Peripheral Arterial Circulation

• Exercises (walking, graded isometric exercises)
• Positioning strategies
• Temperature management (heat/cold applications)
• Smoking cessation
• Stress reduction

Maintaining Tissue Integrity

• Protect extremities from trauma.
• Inspect extremities regularly looking for infections or inflammation
• Maintain good nutrition, low-fat diet
• Weight reduction as necessary

Other Disorders

• Aortic aneurysms (thoracic and abdominal)
• Dissecting aorta

Definition of an Aneurysm

• A localized sac or dilation in an artery's wall, often due to atherosclerosis.
• A significant rupture hazard.

Characteristics of Arterial Aneurysms

• Diagrams illustrate different types including, false, true, fusiform, saccular aneurysms and dissecting aorta, emphasizing the structural differences between these types.

Location of Aneurysms

• Locations of aortic aneurysms (thoracic and abdominal).
• Risk and severity of a dissecting aorta rupture.

Etiology of Aneurysms

• Atherosclerosis
• Hypertension (high blood pressure)
• Cigarette smoking
• Dyslipidemia
• Cellular changes
• Chronic inflammation, aortitis
• Blunt trauma
• Family history

Signs and Symptoms of Aneurysms

• Vague, persistent pain in the chest, back, or abdomen
• Pulsatile mass in the abdomen
• Only 40% of people experiencing AAA will be symptomatic
• Sudden, severe pain is indicative of possible rupture

Diagnostic Tests for Aneurysms

• Chest X-ray
• Contrast aortography
• Computed tomography scan
• Magnetic resonance imaging
• Ultrasound
• Transesophageal echocardiography

Medical Management of Aneurysms

• Watch and wait (monitoring if the size does not increase)
• Lifestyle changes
• Blood pressure (BP) management
• Dyslipidemia (lipid) management

Surgical Management of Aneurysms

• Elective surgery for aneurysms larger than 5 cm in diameter.
• Emergency surgery in case of rupture or tearing.
• Managing blood pressure.
• IV access in two locations.
• Blood pressure monitoring/management using arterial line if needed.
• Pain management.

Post-op Care of Aneurysm Patients

• Manage hemodynamics (BP, O2 levels) monitoring for complications like bleeding.
• Keep patients warm( avoiding cold).
• Reduce risk of intra-thoracic pressure.
• Monitor for infection and thrombosis risk.
• Implement pain management strategies.
• Care for skin/wound.

References

• Includes a reference to a medical-surgical textbook specifically.

Review questions

• Covers a range of assessment and management questions posed.

Additional Questions/Specific Case Studies

• A 50-year-old woman with several PAD risk factors requires a personalized care plan based on identified risk factors.
• Explanation of the relationship between rest pain and arterial blood flow issues in patients.
• A client is admitted for emergency AAA repair due to symptoms like bruising along the flank - related to rupture.
• An individual suffering acute aortic dissection requires pressing initial collaborative care focusing on managing blood pressure.
• Description of the procedure using an intra-arterial balloon to widen a narrow coronary artery, angiography.