Vascular Disorders: Nursing Management

• Moriah Bragg RN. MSN is the author of these notes

Objectives

• Describe the epidemiology of vascular disorders
• Correlate the clinical manifestations and pathophysiological processes of:
  • Atherosclerosis/arteriosclerosis
  • Hypertension
  • Peripheral arterial disease
  • Carotid artery disease
  • Aortic artery disease (aneurysms)
  • Deep vein thrombosis
  • Chronic venous insufficiency
• Describe the diagnostic results that confirm diagnoses of vascular disorders
• Discuss interprofessional management of the conditions above
• Develop comprehensive nursing care plans for patients with vascular disorders
• Design a teaching plan that includes:
  • Pharmacological considerations
  • Dietary considerations
  • Lifestyle considerations

Function of the Vascular System

• Ensures adequate blood circulation to all body tissues
• Facilitates capillary exchange between plasma, interstitial fluid, and tissue cells
• Provides the minimum blood flow per minute to support metabolic activities
• Responsible for waste removal
• Disorders of the vascular system can impair oxygen and nutrient delivery to tissues

Atherosclerosis vs. Arteriosclerosis

• Arteriosclerosis and atherosclerosis are often used interchangeably
• Arteriosclerosis involves the thickening and hardening of arterial walls and reduces elasticity
  • Occurs with aging and includes:
    • Medial calcific sclerosis: Calcium deposits in arteries
    • Arteriolar sclerosis: Thickening of small arterioles
    • Atherosclerosis: LDL cholesterol buildup in arteries
• Atherosclerosis is a type of arteriosclerosis where plaque buildup narrows arteries, increasing the risk for vascular disease

Atherosclerosis - Epidemiology

• Atherosclerosis often begins in childhood and worsens with age
• Linked to conditions such as:
  • Coronary artery disease
  • Carotid artery disease
  • Hypertension
  • Abdominal aortic aneurysm (AAA)
• Risk factors:
  • Lipid abnormalities
    • Cholesterol mismanagement
    • Peripheral arterial disease (PAD)
  • Hypertension
    • Arterial wall damage
  • Diabetes
    • Arterial damage from LDL and hyperglycemia
  • Smoking
  • Family history, obesity, and inactivity
    • High cholesterol poor vascular health
  • Demographics
    • Affects men earlier than women

Atherosclerosis - Pathophysiology

• Atherosclerosis is a chronic disease where LDL cholesterol builds up in the arterial walls
• Leads to inflammation and plaque formation
• Key process:
  • Vessel damage and inflammation: Injury to the arterial wall triggers an inflammatory response
  • Fatty streak formation: Lipids deposit on the artery's inner lining and are oxidized by macrophages, worsening inflammation
  • Plaque development: The artery thickens, narrowing the vessel and reducing blood flow and limiting oxygen supply
  • Plaque rupture: Unstable plaques can break open, leading to blood clots that may block arteries or travel elsewhere, causing severe complications

Atherosclerosis - Clinical Manifestations

• Atherosclerosis may be asymptomatic
• This is until a significant artery narrowing leads to an emergency
• Symptoms depend on the affected artery:
  • Coronary arteries can cause:
    • Chest pain (angina)
    • Shortness of breath
    • Fatigue
    • Arrhythmias
    • Myocardial infarction (MI)
    • Sudden cardiac death
  • Carotid arteries may lead to stroke, with symptoms like:
    • Sudden weakness (often one-sided)
    • Dizziness
    • Loss of coordination
    • Speech difficulty
    • Facial droop
    • Vision problems
    • Severe headache
  • Peripheral arteries: Reduced blood flow to the limbs can cause:
    • Pain
    • Difficulty walking
    • Severe cases of tissue death (gangrene), most commonly in the toes, fingers, hands, and feet

Atherosclerosis - Management

• Medical management focuses on:
  • Gaining control of risk factors
  • Lowering LDL cholesterol levels
• Medications include:
  • Lipid-lowering medications: Atorvastatin, simvastatin
  • Anticoagulation: Apixaban, enoxaparin
• Lifestyle modifications include:
  • Healthy diet
  • Smoking cessation
  • Exercise
  • Stress management
  • Diabetes control (if applicable)
• Surgical management is reserved for severe cases with irreversible manifestations
  • Intractable chest pain related to coronary artery disease, requiring coronary revascularization
  • Gangrene that may require amputation

Atherosclerosis - Nursing Management

• Assessments:
  • Symptoms are dependent upon affected arteries
  • Patient history and cardiovascular exam identifies genetic and environmental risk factors
  • Blood pressure (BP) in both arms; hypertension is a key risk factor
  • Palpation of pulses; weak pulses suggest poor circulation
  • Auscultation for bruits: Indicates narrowed arteries but not severity
  • Fasting lipid profile:
    • LDL-C (>100 mg/dL = Risk)
    • HDL-C (<40 mg/dL = Risk)
    • Triglycerides (>150 mg/dL = Risk)
  • Homocysteine levels: High levels may promote plaque buildup
  • Hemoglobin A1c: >7% may indicate poor diabetes control, increasing risk
• Actions:
  • Administer prescribed medications as ordered
    • Antihypertensives
    • Lipid-lowering therapy (statins)
• Patient teaching:
  • Blood pressure management: Take medications as prescribed
  • Lifestyle modifications
    • Healthy diet: Low-fat, low-cholesterol, high in B-complex vitamins
    • Smoking cessation: Reduces LDL-C and prevents endothelial damage
    • Exercise: Lowers LDL-C, raises HDL-C, and improves BP, diabetes, obesity, and stress

Hypertension

• A common chronic condition
• 47% of U.S. adults have hypertension
• Risk factors:
  • Age: BP increases with age
  • Sex: Before age 45, more common in males; after age 65, more common in females
  • Race: Black adults have the highest prevalence, morbidity, and mortality
  • Socioeconomic status: More common in low-income populations
• Types of hypertension:
  • Primary (essential) hypertension: No identifiable medical cause
    • Risk factors:
      • Obesity
      • Salt sensitivity
      • Renin elevation and insulin resistance
      • Vitamin D deficiency
      • Smoking
  • Secondary hypertension: Due to an identifiable cause
    • Renal parenchymal disease (most common)
    • Renovascular disease
    • Endocrine disorders
    • Congenital conditions
    • Substance related cause
• Clinical manifestations:
  • Hypertension is often silent
  • Target organ damage before awareness
  • Symptoms may include:
    • Headaches
    • Dizziness
    • Vision changes
    • Chest pain
    • Shortness of breath
    • Fatigue
    • Nosebleeds
    • Kidney dysfunction (elevated creatinine, decreased urine output)
    • Secondary hypertension symptoms depend on the underlying cause (e.g., kidney disease, hormonal disorders)
• Diagnosis:
  • After two or more high BP readings across separate visits
  • Treatments may start immediately if BP is extremely high during one visit
  • Testing can be done to identify target organ damage:
    • Heart,
    • Kidneys
    • Eyes
• Treatment:
  • Lifestyle changes:
    • Weight control
    • Diet
    • Alcohol
    • Exercise
    • Stress management
  • Medications:
    • Antihypertensives
    • Diuretics
• Complications:
  • Heart damage and is a "silent killer"
    • Arterial pressure leads to left ventricular hypertrophy, and resulting heart failure
  • Kidney damage
    • Reduced renal blood flow leads to renin production, increased BP, and kidney cell death
  • Stroke and aneurysms
    • High BP can cause vessel rupture and hemorrhagic stroke
    • High BP leads to aneurysm formation and potential rupture
  • Hypertensive crisis and is a severe BP spike
    • Hypertensive urgency: BP ≥120 mm Hg diastolic without acute organ damage
    • Hypertensive emergency: High BP with target organ damage (e.g., stroke, heart failure, or aortic dissection), requiring immediate intervention; More common in older adults, Black individuals, males, and often due to medication withdrawal or uncontrolled chronic hypertension
• Nursing management:
  • Silent disease
    • No formal symptoms until organ damage occurs
    • Conduct a physical exam and be sure to monitor BP
  • Neurological assessment
    • S/S of stroke or aneurysm
  • B/P monitoring
  • Heart rate
    • Increased HR to compensate for increased peripheral vascular resistance Auscultation of bruits
    • R/T narrowed vessels
• Nursing actions:
  • Administer antihypertensive as prescribed,
  • Provide DASH diet which includes:
    • Low sodium, high in fruits, vegetables and low-fat dairy
• Provide pt education
  • Medication adherence and lifestyle changes.
    • MODERATE EXERCISE
    • LIMIT ALCOHOL
    • STRESS MANAGEMENT
    • SMOKING CESSATION.

Peripheral Artery Disease (PAD) - Epidemiology

• Impacts Over 230M people Globally
• Primary cause is Atherosclerosis
• Modifiable risk factors:
  • Stress management
  • Smoking
  • Diet
  • Exercising
  • Managing lipids
  • HTN
  • Diabetes
  • obesity
• Non modifiable risk factors:
  • Age
  • Sex
  • Ethnicity
  • Family history
• Can lead to peripheral and coronary artery disease

Peripheral Artery Disease (PAD) - Pathophysiology

• Progressive condition
• Largely impacts peripheral arteries that become blocked
• Ischemia/tissue damage caused by:
  • Atherosclerosis
  • Inflammation
  • Thrombus
• May result in Necrosis and will reduce oxygen/nutrient delivery

Peripheral Arterial Disease : Examples

• “Six Ps” of ischemia:
  • Pain
  • Pallor
  • Pulselessness
  • Paresthesia
  • Paralysis
  • Poikilothermia

Clinical Manifestations of Peripheral Arterial Disease

• Varies From asymptomatic to pain during activity relieved w/ rest
  • Joint Pain
  • cold extremeties
  • Limitation in Mobility
  • Decreased Quality of Life

Peripheral Arterial Disease Tests/Diagnosis and Treatment(s):

• Ankle-Brachial Index (ABI) : compares BP in ankle w/ the arm pressure
  • A value of less than 0.9 indicates the condition
• Plethysmography can assess changes in blood volume in the limbs
• Treadmill Tests: Identifies severity of claudication
• Duplex ultrasounds: Measures velocity of blood
• CTA and MRA: Imaging for more defined arterial vessel function
• Angiography is reserved for more severe cases: Can lead to treatment like angioplasty or bypass

Peripheral Arterial Disease Treatment - Surgical and Nonsurgical:

- Treatments range from nonsurgical treatments such as:
    - weight loss
    - Smoking cessation
    - Exercise
    - Medications ( Anti-hypertensive's , Metoprolol, Losartan, Statins such as Atorvastatin and Simvastatin or Antiplatelets such as Aspirin, Clopridogrel
- To more evasive Surgical Treatments:
    - Revascularization such as Bypass or Balloon Angioplasty

Additional PAD Info

- Can be a severe case called Crictital Limb Ischemia. Symptoms Include:
    - Ulcers
    - Gangrene
    - Limb loss
- Or an acute case can occur called Acute Limb Ischemia where there is not enough or sudden loss of blood flow:
    - Requires urgent intervention to save limbs

Additional Nurse Management for PAD:

- Always assess:
    - Pulses
    - Temperatures
    - Color
    - Pain
    - Signs of infections
    - Ulcers ( Mostly diabetic pt's)

• Nurse interventions can consist of:
  • Medications
  • Proper Limb position to get correct blood flow
  • Encouraging exercises
  • Helping educate to ensure lifestyle changes pt understands
    • Will need to inspect feet
    • Avoid limb compression ( Crossing legs )
    • Pt will need to be constantly aware of any new symptoms w/ chest or neurological

Carotid Artery Disease Facts, Risk Factors, Pathophysiology and Symptoms:

• Common in aging adults and Individuals w/:
  • Non modifiable risk factors:
    • Age
    • Sex
    • Ethnicity -Risk Factors include modifiable ones:
    • Smoking
    • HTN
    • Diabetes
    • Dyslipidemia
    • Obesity
    • Sedentary lifestyle
  • Pathophysiology: - Plaque build up leads to narrowing of vessels and increased stroke risk

More Carotid Artery Info

• Asymptomatic signs until cerebral perfusion is impaired
  • Carotid bruit is very prevalent ( murmur like sound heard when arteries become narrow)
  • Stroke/ TIA symptoms:
    • Weakness to one side
    • Dizziness
    • Vision problems
    • Difficult speaking
    • Facial drooping or headache
• Can be found in Physical exam or tested through: - Non- invasive tests such as Duplex ultrasounds - Invasive testing such as Carotid Angiography ( most accurate)

Treatment Protocols & Nurse Responsibilities for Carotid Artery:

• Treatment can vary from simple lifestyle changes all the way surgical:
  • Invasive surgical solutions include:
    • Carotid endarterectomy or stenting
• Always make sure to give anticoagulants to the pt such as: - Aspirin and clopidogrel -Nurse duties may include: - Constant Neurological function post stroke or carotid function - Routine assessment w/ bruising and cranial nerve damage - Monitor kidney function post procedures

Aortic Artery Disease (Aneurysms):

• approx 15,000 deaths in the US (AAA)
• Men and those w/ HTN are at higher risk
• Risk Factors:
  • Family history
  • Age , smoking, athersosclerosis, HTN, high cholesterol and genetic conditions like "Marfan's Syndrome" increase risk
• Pathology lies with the arteries that dilate and weaken
  • HTN and assc cause artery inflammation
• 3 types of Aortic aneurysms occur, they are:
  • Ascending (Arch)
  • Decending (Thoracic)
  • Abdominal
  • Most aneurysm pts are asymptomatic until compilations
• Symptoms of such condition include:
  • pulsatile abdominal mass -Chest, back or flank pain
• can be tested through CT Scans and ECG's
• Complications may cause severe back pain requiring an immediate intervention

More Aortic Disease info Continued:

• If test result come back positive medications such as:
• antihypertensives or statins
• Surgical protocol is to cut the bulging aneurysm out. Or insert endovascular repairs to stabilize blood flow.*

Always use assessment to determine a good care plan for the pt to recognize symptoms

More Vascular Issues:

• Blood clots, better known as Deep Vein Thrombosis (DVT):
• typically in the leg or pelvis -Affects approx 1/1000 ppl
  • traveling clots can lead to lungs an can lead to Pulmonary embolism
• Hospitalizations are a major risk, this may be from:* -:Immobility: and :Surgery: -Additional Risks may Include:
  • Age, cancer, surgery, immobility, pregnancy, oral contraceptive and covid-19 (as of documentation)

Symptoms an Treatment for DVT pt's

• Pathology consists of: blood stasis - endo injury and over coagulating
• Symptoms can entail Swelling
  • redness and soreness to the area
  • Homan's sign is a sign of pain, but is not reliable on its own
• Medical Testing is administered from:
  • wells testing to measure, D-Dimer lab testing, ultrasounds
  • Surgery's may be needed from thrombolytic's if critical or Vena Cava

More DVT protocols

• Amubulation is good practice for keeping blood moving after post procedure

• medication: heparin is a good drug for immediate treatment or for long term use there is "warfarin and rivaroxaban"

• Thrombolytics: Are usually to be reserved for severe cases as they carry bleeding risks

• DVT and Pulmonary embolism are two major complications to watch out for!

Best Nurse Advice to give the pt w/ DVT

• Early ambulation and leg elevation
• Compression use and routine extremity checks
• Educate the pt on activity levels and routine lab checks to ensure medications are balancing correctly!

Chronic Venous Insufficiency Complications:

• Most often progressive from chronic venous disease: causes swelling in the legs and skin changes

• Is a result from HTN - effects 6.7 MILLIONS

More Info:

• Can derive from : Primary or Secondary dysfunctions:
  • Valve dysfunction,
  • Deep vein thrombosis
• Can find incompetent vessels with leg pain
• Or skin discoloration and swelling in area (Possible Necrosis)

Tests and More Pt Care Advise

• No one test is accurate. but skin changes, pressure and blood flow are good data for assessment
• Treatment is compression bandage therapy
• Can administer: antibiotics, and asspirin to help aide. -
• Surgical procedures involve*: - Ablation and microphlebectomy's - always keep legs elevated and give proper nutrition.